Shorter Oxford Textbook of Psychiatry, 6th Ed.

CHAPTER 15. Psychiatry and medicine

Psychiatry, medicine, and mind–body dualism

Epidemiology of psychiatric disorder in medical settings

The presentation of psychiatric disorder in medical settings

Comorbidity: the co-occurrence of psychiatric and medical conditions

Management of psychiatric disorder in the medically ill

Somatic symptoms that are unexplained by somatic pathology

Somatoform and dissociative disorders

Psychiatric services in medical settings

Psychiatric aspects of medical procedures and conditions

Psychiatric aspects of obstetrics and gynaecology

This chapter considers the relevance of psychiatry to the rest of medical practice. It should be read in conjunction with the other chapters in this book, especially Chapters 8 and 13.

Psychiatry, medicine, and mind–body dualism

Patients usually attend their doctors because of symptoms which are causing distress and/or dysfunction—that is, when they have an illness. Medical assessment is directed at making a diagnosis of the illness, and this diagnosis is used to guide the plan of management. The diagnosis is conventionally defined as either medical or psychiatric.

Medical diagnosis

Most medical diagnoses are based on symptoms and physical signs and the results of biological investigations that together indicate the presence of bodily pathology (abnormal structure and/or function), which is referred to as disease. Not all medical diagnoses are arrived at in this way (e.g. migraine), and ultimately a medical diagnosis is a label for a condition that is conventionally treated by medical doctors and listed in classifications of disease such as ICD-10.

Psychiatric diagnosis

Psychiatric diagnosis was discussed in Chapter 2, and the following brief account is intended to remind the reader of that discussion. A psychiatric diagnosis, like a medical one, is essentially a label for a condition that is conventionally treated by doctors, sometimes psychiatrists, but also other practitioners. Psychiatric diagnoses are listed in the classifications of diseases, along with medical diagnoses, but although some have associated physical pathology, many do not. Because they usually lack known pathology, they are generally referred to as disorders rather than diseases.

In the past, psychiatric diagnoses have been regarded as ‘mental’ in nature, in contrast to the ‘physical’ nature of medical diagnoses. This distinction reflects the absence of gross pathology in most psychiatric disorders, and the fact that these conditions usually present with disturbed mental states or behaviour, rather than physical symptoms. Presentations with physical symptoms are considered later in this chapter.

Medicine, psychiatry, and dualism

Underlying this division of illnesses into physical and mental is the assumption that a parallel distinction can be made in healthy people—that there is ‘mind–body dualism’, an idea commonly attributed to the philosopher Descartes. So-called Cartesian dualism has and continues to exert a profound influence on Western medical thinking (Miresco and Kirmayer, 2006). Although this division has some utility, it can also be problematic.

Limitations of dualism

Dualism is at best an oversimplification. It can be convincingly argued that there are no such things as purely physical or psychological conditions, whether in health or illness. The associated assumption that psychological symptoms indicate psychopathology and physical symptoms indicate physical pathology leads to the categories shown in Table 15.1. Two of these, disease and disorder, have been considered. The other two, comorbidity and somatization, will be considered next.

Comorbidity refers to the co-occurrence of two disorders. The term has been extended in the table to describe the co-occurrence of prominent mental symptoms and bodily pathology, as these patients are usually given both a psychiatric and a physical diagnosis (Kisely and Goldberg, 1996). In practice neither of these diagnoses may lead to effective treatment, because a focus on either one of them may lead to neglect of the other. An example is the widespread neglect of depression in patients with medical disease (Moussavi et al., 2007).

Somatization. Some patients have somatic symptoms but no evidence of bodily pathology (DeGucht and Fischler, 2002). It is then unclear whether their illness should be categorized as medical (with presumed but unidentified somatic pathology) or as psychiatric (with assumed psychopathology). In the past these conditions were generally given the medical diagnosis of functional illness (function is abnormal, but there is no pathology). Now these conditions are usually given the psychiatric diagnosis of somatoform disorder. This diagnosis implies first that the somatic symptoms are caused by psychopathology, and secondly that there is a hypothetical process—somatization—by which the psychopathology has caused the bodily symptoms. Such patients can therefore receive both a medical diagnosis (functional disorder) and a psychiatric diagnosis (somatoform disorder), and the resulting confusion and controversy are well illustrated by the literature on the condition known as chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME) (Sharpe, 2002).

Practical consequences of dualism

One consequence of this way of thinking is the professional and organizational separation of medicine and psychiatry, which in turn contributes to its persistence. This makes it is difficult to provide integrated care for patients with comorbidity and those with somatoform disorders. One organizational response to this problem has been the establishment of liaison psychiatry services to general hospitals (see below).

An integrated approach

New scientific knowledge, such as the demonstration of a neural basis to many psychiatric disorders, has shown that crude dualistic thinking is untenable. Evidence for the effect of psychiatric disorder on the outcome of medical conditions such as myocardial infarction (Meijer et al., 2011) has pointed to the same conclusion. Mind and brain are now increasingly regarded as two sides of the same coin. This paradigm shift implies that psychiatric disorders are no more distinct from medical conditions than the higher nervous system is from the rest of the body (Sharpe and Carson, 2001). Correspondingly, medical care and psychiatric care need to be more integrated (Mayou et al., 2004).

Table 15.1 Traditional ‘dualistic’ categories of mental and physical illness

Images

For the present, dualism continues to shape everyday thinking and practice. Illnesses are given separate medical and psychiatric diagnoses linked to separate knowledge bases and distinct systems of care. The psychiatrist working in medical settings needs to be aware of these problems and help to address them by ensuring that the biological, psychological, and social aspects of illness are considered in every case. This is referred to as the biopsychosocialapproach, which was proposed many years ago by Engel (1977) (and which is implicitly if not explicitly adopted throughout this book). The factors that need to be considered in a biopsychosocial formulation are listed in Table 15.2. They can be divided further into predisposing, precipitating and perpetuating causes. The last group of causes is the usual target for treatment, while the first two are relevant to prevention.

Table 15.2 The biopsychosocial formulation

Biological factors

Disease

Physiology

Psychological factors

Cognition

Mood

Behaviour

Social factors

Interpersonal

Social and occupational

Relating to the healthcare system

Epidemiology of psychiatric disorder in medical settings

Although psychiatric disorder is common in all settings, the type and presentation of psychiatric disorders differ from one medical setting to another. The most common diagnoses in each setting are shown in Table 15.3.

General practice

The most common psychiatric disorders in general practice are the somatoform disorders, depression, anxiety and stress-related disorders, and substance misuse. Patients with psychosis are uncommon (Ansseau et al., 2004).

Casualty departments

Deliberate self-harm is the major psychiatric problem in casualty departments. Although only a minority of these patients have persistent psychiatric disorders, many have stress-related disorders and some have depressive disorders. Intoxication and delirium related to alcohol and drugs are also common, particularly in inner-city hospitals and among people involved in accidents. Some patients with somatoform disorders and a few with factitious disorders (see p. 391) are frequent attendees at casualty departments (Wooden et al., 2009).

Table 15.3 The relative prevalence of common psychiatric disorders in medical settings other than psychiatry

Images

Medical and surgical outpatient clinics

About one-third of people attending medical and surgical outpatient clinics have a psychiatric disorder (Maiden et al., 2003). Half of these have depressive and anxiety disorders, and most of the remainder have somatoform disorders. In both groups, adequate recognition and treatment of the psychiatric disorder should be an integral part of management, since it has been shown to improve outcome. Depression is a common cause of apparent worsening of a medical condition.

Medical and surgical wards

Around 20% of medical and surgical inpatients have a depressive or anxiety disorder coexisting with their medical disease, 10% have a significant alcohol misuse problem, and 25% of elderly inpatients have an episode of delirium (Saxena and Lawley, 2009). Some patients with severe somatoform disorders undergo multiple investigations and even surgery before the diagnosis is made.

The presentation of psychiatric disorder in medical settings

Although psychiatric disorders commonly present in medical settings with psychological symptoms or behavioural disturbance, other less obvious presentations frequently occur. These are as somatic symptoms, a medical management problem, or an apparent exacerbation of a medical condition.

Psychiatric disorder presenting with somatic symptoms

A significant minority of patients who are seen in general practice and in hospital outpatient clinics have somatic symptoms which cannot be explained by medical disease, and many of these have a psychiatric disorder (Steinbrecher et al., 2011).

Somatic symptoms due to depressive and anxiety disorders. Depression is associated with somatic symptoms, such as fatigue, weight loss, and pain, which may lead to referral to a medical specialty. Anxiety is associated with symptoms of autonomic arousal, such as palpitations, and with breathlessness and sensory symptoms. A World Health Organization collaborative study of patients presenting to primary care in 14 countries found a strong association between somatic symptoms and depressive and anxiety disorders in all centres, despite different cultures and health services. Also, there was a linear relationship between the number of somatic symptoms and the presence of depression and anxiety disorder (Simon et al., 1999). Among the anxiety disorders, panic disorder is an especially important cause of medically unexplained symptoms such as chest pain, dizziness, and tingling (Katon, 1996).

Somatoform disorders. Medically unexplained somatic symptoms in the absence of a depressive or anxiety disorder are diagnosed either as medically unexplained symptoms or alternatively as somatoform disorders. Somatoform disorders are diagnosed when there is a strong suspicion of a psychogenic cause, not just as a diagnosis of exclusion.

Psychiatric disorder presenting as apparent worsening of a medical condition

An exacerbation of complaints about symptoms or disability associated with a chronic medical condition is sometimes caused by a comorbid depressive disorder.

Refusal of treatment is sometimes the first pointer to a psychiatric disorder.

Comorbidity: the co-occurrence of psychiatric and medical conditions

Comorbidity of psychiatric disorders with medical conditions is important. For example, an eating disorder may greatly complicate the treatment of diabetes, and depression is a risk factor for increased mortality and morbidity following myocardial infarction.

Epidemiology

Psychiatric disorder is present in as many as one-third of patients with serious acute, recurrent, or progressive medical conditions. It is difficult to ascertain the exact proportion because standard criteria for the diagnosis of psychiatric disorder include some symptoms that can also be caused by medical illness (e.g. fatigue and poor sleep). Although modifications have been suggested to make the criteria more appropriate for use in individuals with physical as well as psychiatric disorder, none of them are wholly satisfactory. It is best to start with standard criteria and then use knowledge of the medical condition to decide which of the symptoms that point to psychiatric disorder could have originated in this other way. However, this approach requires skilled interviewers and is difficult to achieve on a large scale.

Suicide is easier to identify, and there is an increased risk in the medically ill compared with the general population. Associations have been reported with cancer, multiple sclerosis, and a number of other conditions (Druss and Pincus, 2000).

Common associations between psychiatric and physical illness are shown in Table 15.4. For a review of the epidemiology of psychiatric disorder in association with medical illness, see Mayou and Sharpe (1995).

The importance of psychiatric comorbidity in the medically ill

A comorbid psychiatric disorder can greatly affect the impact and outcome of medical conditions—for example, in patients with ischaemic heart disease (Surtees et al., 2008) and diabetes (Lin et al., 2010). Anxiety and depression are also risk factors for non-compliance with medical treatment (Rieckmann et al., 2006).

Table 15.4 Psychiatric disorders that are common in the medically ill

Adjustment disorder

Major depression

Anxiety disorder

Generalized anxiety disorder

Panic disorder

Phobic disorder

Acute stress disorder

Post-traumatic stress disorder

Somatoform disorder

Substance misuse

Eating disorder

Sleep disorder

Factitious disorder

Sexual disorders

The causes of psychiatric comorbidity in the medically ill

Psychiatric disorder may be present in medical patients for three main reasons:

1. by chance, as both are common

2. the psychiatric disorder may have caused the medical condition (e.g. alcohol dependence causing cirrhosis of the liver)

3. the medical condition may have caused the psychiatric disorder, either through an action of the disease or its treatment on the brain, or as a reaction to the psychological impact of the medical condition or its treatment, or as a result of the social effects of the medical condition or its treatment (e.g. loss of employment). These factors interact with the person’s premorbid vulnerability.

The medical condition and its treatment

Biological mechanisms

In addition to delirium and dementia, a number of other psychiatric disorders may be caused by the effects of the medical condition on the brain. Conditions that may act in this way include acute infection, endocrine disorders, and some forms of malignancy. This resulting psychiatric condition is referred to in DSM as organic mental disorder. The principal medical conditions that may act in this way are listed in Table 15.5.

Medical treatment may also cause psychiatric disorder by its effect on the brain. Table 15.6 lists some commonly used drugs that may produce psychiatric disorder as a side-effect. Other treatments associated with psychiatric disorder include radiotherapy, cancer chemotherapy, and mutilating operations such as mastectomy.

Psychological and social mechanisms

The most common means by which a medical condition can cause psychiatric disorder is by its psychological impact. Certain types of medical condition are particularly likely to provoke serious psychiatric consequences. These include life-threatening acute illnesses and recurrent progressive conditions. Psychiatric disorder is more common in chronic medical illness if there are distressing symptoms such as severe pain, persistent vomiting, and severe breathlessness, and when there is severe disability (Katon et al., 2007).

Table 15.5 Medical conditions that may cause psychiatric disorder directly

Depression

Carcinoma

Infections

Neurological disorders (see Chapter 13)

Diabetes, thyroid disorder, Addison’s disease

Systemic lupus erythematosus

Anxiety

Hyperthyroidism

Hyperventilation

Phaeochromocytoma

Hypoglycaemia

Drug withdrawal

Some neurological disorders (see Chapter 13)

Patients at risk for both acute and persistent psychiatric disorder in the course of medical illness include those who:

• have developed psychological problems in relation to stress in the past

• have suffered other recent adverse life events

• are in difficult social circumstances.

The reactions of family, friends, employers, and doctors may affect the psychological impact of a medical condition on a patient. They may reduce this impact by their support, reassurance, and other help, or they may increase it by their excessive caution, contradictory advice, or lack of sympathy.

Prevention of psychiatric disorder in the medically ill

There are three main strategies—first, to identify those at risk, secondly, to minimize the negative effect of illness by providing good medical and nursing care, and thirdly, to detect early and treat effectively the early stages of any psychiatric disorder. Prevention should focus on patients who are suffering illnesses or undergoing treatments which are known to be associated with the development of psychiatric disorder, and on individuals who are psychologically vulnerable as evidenced, for example, by a previous history of psychiatric disorder.

Table 15.6 Some drugs with psychological side-effects

Images

Effectiveness of psychiatric treatments in the medically ill

Clinical experience indicates that psychiatric treatments are generally effective in patients who are also medically ill, although there was limited evidence from randomized controlled trials, because comorbid patients are usually excluded. However, there are now more trials of antidepressants in medically ill patients, and a clearer indication of their value (Taylor et al., 2011). Clinical experience also suggests that psychological treatments such as cognitive–behaviour therapy are effective in medically ill patients, but again there is little evidence from clinical trials. There is better evidence for the benefits of ‘collaborative care’, in which medical treatment and psychiatric treatment are coordinated. This is especially relevant in the management of chronic medical conditions (Katon, 2003), where there is evidence of considerably reduced treatment costs, primarily because of shorter inpatient stays (Koopmans et al., 2005).

Management of psychiatric disorder in the medically ill

Assessment

Assessment is as for psychiatric disorder in other circumstances, but in addition it is necessary to:

• be well informed about the medical condition and its treatment

• distinguish anxiety and depressive disorders from normal emotional responses to physical illness and its treatment. Symptoms that seldom occur in normal distress (e.g. hopelessness, guilt, loss of interest, and severe insomnia) help to make the distinction

• be aware that medical conditions and their treatment may cause symptoms such as fatigue and loss of appetite that are used to diagnose psychiatric disorder

• explore the patient’s understanding and fears of the medical condition and its treatment.

General considerations

The nature of the medical condition and its treatment should be explained clearly and the opportunity provided for the patient to express their worries and fears. The treatment for the associated psychiatric disorder is undertaken using the methods appropriate for the same disorder in a physically healthy person. Careful consideration should be given to possible interactions between the proposed psychiatric treatment and the medical condition and its treatment. Treatment can often be given by the general practitioner or medical specialist, but more complex cases require the skills of a psychiatrist.

Medication

Hypnotic and anxiolytic drugs can provide valuable short-term relief when distress is severe. The indications for antidepressants are the same as those for patients who are not physically ill. The side-effects and possible interactions of the psychotropic drugs with other medication should be considered carefully before prescribing.

Psychological treatments

Explanation and advice are part of the treatment of every patient. Cognitive–behaviour therapy may be chosen in order to reduce distress, increase adherence to treatment, reduce disproportionate disability, and modify lifestyle risk factors.

Somatic symptoms that are unexplained by somatic pathology

Somatic symptoms that are not clearly associated with physical pathology are common in the general population and in patients in all medical settings (Mayou and Farmer, 2002). Although most of these symptoms are transient, a minority are persistent and disabling, and a cause of frequent medical consultations. Some conditions that may give rise to somatic symptoms are shown in Table 15.5.

As noted already, the most common association with psychiatric disorder is with anxiety and depressive disorders, and some conditions meet the criteria for a somato-form disorder (see p. 393). A few of these patients have a factitious disorder, and a very small number are malingering. However, many of those who present to doctors with unexplained somatic symptoms do not meet the diagnostic criteria for any of these conditions. Even in these undiagnosed cases, however, psychological and social factors are often important as causes of the symptoms and as reasons for seeking help, and psychological measures are often helpful.

Terminology

Many terms have been used to describe medically unexplained somatic symptoms, none of which is wholly satisfactory. These terms include hysteria, hypochondriasis, somatization, somatoform symptoms, functional somatic symptoms, and functional overlay. Some of these terms will now be considered further.

• Somatization. This term was introduced at the beginning of the twentieth century by Wilhelm Stekl, a German psychoanalyst, to describe the expression of emotional distress as bodily symptoms. More recently, the term has been used to describe the disorder as well as the process that produces it. Some current usage is even broader, covering the perception of bodily sensations as symptoms and the behaviour of consulting about them. Most usage accepts, explicitly or implicitly, Stekl’s original idea that physical symptoms are an expression of psychopathology—for example, ‘a tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them’ (Lipowski, 1988). Some definitions of somatization reject Stekl’s view and use criteria that require physical symptoms to be accompanied by anxiety or mood disorder diagnosed according to standard criteria. Also, current research suggests that emotional distress and somatic symptoms are positively related rather than inversely related as they would be if they were alternative expressions of an underlying psychopathology. Because there is no agreed definition, and because of the unsubstantiated aetiological assumptions, the term ‘somatization’ is unsatisfactory.

• Somatoform disorder. This term was originally used in DSM-III to describe a group of disorders including both traditional psychiatric diagnoses, such as hysteria and hypochondriasis, and newly proposed categories, such as somatization disorder. The somatoform disorders are discussed on pp. 393–401.

• Functional somatic symptoms. This term, which is often used by physicians, refers to a condition caused by a disturbance of bodily function without any known pathology. The term is relatively acceptable to patients, but the use of the word ‘functional’ (as opposed to ‘organic’) has been criticized.

• Medically unexplained symptoms. This term has the advantage of describing a clinical problem without implying any assumptions about its causes. However, it has been criticized as implying that understanding of the condition is not possible. Despite this limitation we use it in this chapter.

Epidemiology

Medically unexplained symptoms are common in the general population and in people attending primary care, and they are more frequent in women than in men (Guthrie, 2008). Although the majority of these symptoms are recognized as not serious, and most of them are short-lived, a sizeable minority lead to distress, functional disability, and role impairment, with more time off work, consulting doctors, and taking medication (Harris et al., 2009).

Aetiology

Although unexplained by any physical pathology, something is known about the causes of medically unexplained symptoms. Most arise from misinterpretation of the significance of normal bodily sensations, which are interpreted as a sign of disease. Concern leads to the focusing of attention on the sensations and this leads to even greater concern, apprehension, and anxiety, which exacerbate and maintain the symptom. For example, awareness of increased heart rate when a person is excited or anxious may lead to worry about heart disease, restriction of daily activities, and repeated requests for investigation and reassurance. Good communication by clinical staff can help to counter the effects of such misinterpretations.

Table 15.7 lists the sources of bodily sensations that may be misinterpreted as symptoms of disease.

Table 15.7 Physiological sources of bodily sensations

Sinus tachycardia and benign minor arrhythmias

Effects of fatigue

Hangover

Effects of overeating

Effects of prolonged inactivity

Autonomic effects of anxiety

Effects of lack of sleep

Predisposing factors include the following:

• Beliefs about illnesss shape a person’s response to sensations and symptoms. These beliefs may be related to personal experience of illness in earlier life, to involvement in the illness of family or friends, or to portrayals of illness in the media (see Table 15.8).

• Adverse experiences in childhood. Adults with medically unexplained symptoms commonly report adversities in childhood (e.g. poor parenting and various forms of abuse).

• Social circumstances. Medically unexplained symptoms are associated with poor socio-economic circumstances and acute or chronic adversity.

• Personality. Some people with medically unexplained symptoms have had concerns about bodily health going back to adolescence or earlier, and these can be viewed as part of their personality.

Perpetuating factors include the following:

• Behavioural factors, such as repeatedly seeking information about illness, and inactivity.

• Emotional factors, especially chronic anxiety and depression.

• The reactions of others, including doctors as well as family and friends. Doctors may inadvertently prolong the problem by failing to give clear, relevant information that takes into account the patient’s individual fears and other concerns.

For a review of the causes of unexplained symptoms, see Kanaan et al. (2007).

The classification of medically unexplained symptoms

The classification of medically unexplained symptoms has been considered from two perspectives.

1. The medical approach has been to identify patterns of physical symptoms, such as irritable bowel syndrome and fibromyalgia. The syndromes differ somewhat in different countries. For example, low blood pressure syndrome is accepted in Germany, and mal de foie in France, but neither is accepted in England. These are descriptive syndromes, not aetiological entities, and they overlap with other disorders (Wessely et al., 1999). Diagnostic criteria have been produced for some of these syndromes, and these criteria are useful in research and service planning.

2. The psychiatric approach has been to attempt to identify psychiatric syndromes that are the basis of the symptoms. These include anxiety and depressive disorders, somatoform disorder, and factitious disorder. A psychiatric diagnosis and a medical diagnosis can be made in the same patient. For example, a patient with chest pain and no heart disease may receive a medical diagnosis of ‘non-cardiac chest pain’ and a psychiatric diagnosis of ‘panic disorder’, both describing the same symptoms.

Table 15.8 Experiences which may affect the interpretation of bodily sensations

Childhood illness, with encounters with medical services, and absence from school

During childhood, illness of close family members

Physical illness in adulthood

In adulthood, illness among family and friends

Accounts of illness in the media

Other sources of information about illness

Prevention of medically unexplained symptoms

Until we know more about the causes of medically unexplained symptoms, there is no solid basis for prevention. Although a reduction in predisposing factors in the population, such as childhood abuse and poor parenting, might have some effect, if it was achievable, it is more plausible to address factors such as poor communication by doctors (Ring et al., 2004) and inadequate treatment of depression and anxiety in patients who present with somatic complaints. For a fuller discussion of prevention, see Hotopf (2004).

Treatment of medically unexplained symptoms

There is rather more evidence about the effectiveness of treatments for medically unexplained symptoms. There have been some trials of medication and of cognitive–behaviour therapy, some of which are cited in the course of this chapter.

Antidepressant medication has been shown to benefit several kinds of medically unexplained symptoms, including fibromyalgia and irritable bowel syndrome. Facial pain may be helped by tricyclic antidepressants. This benefit occurs especially (but not exclusively) in patients with marked depressive symptoms (Sumathipala, 2007).

Cognitive–behaviour therapy is moderately effective in the treatment of non-cardiac chest pain, irritable bowel syndrome, and chronic fatigue syndrome (Sumathipala et al., 2008).

Management of medically unexplained symptoms

Assessment

An adequate medical assessment is essential. At the end of this the physician should explain:

• the purpose and results of all the investigations that have been carried out, and why it has been concluded that there is no medical cause for the symptoms

• that the symptoms are nevertheless accepted as real, and that it makes sense to look for other causes.

If the patient is then referred to a psychiatrist, the latter should be informed about the results of the investigations, and about the way that these have been explained to the patient.

The psychiatrist explores the nature and significance to the patient of the unexplained symptoms, and completes the usual psychiatric history and a mental state examination, giving particular attention to:

• previous concerns about illness

• current beliefs about illness

• personality

• social and psychological problems

• detection of a depressive or anxiety disorder.

Information should be sought from other informants as well as from the patient.

Management

The basic plan of management is the same for all medically unexplained symptoms, but individual treatment plans should take account of the patient’s special concerns, the type of unexplained symptoms, and any associated psychiatric disorder.

The management of chronic fatigue syndrome and some other special functional medical syndromes is discussed below. The management of somatoform disorders is described later in the chapter.

After the basic procedures outlined in Box 15.1 have been completed, many patients will be reassured. Those who are not may seek repeated investigation and reassurance. Therefore, when all of the medically necessary investigations have been completed, the clinician should explain thoroughly why no further investigation is required. After these initial discussions, it is seldom helpful to engage in repeated arguments about the causes. Most patients are willing to accept at least that psychological as well as biological factors may influence their symptoms, and this acceptance can provide a basis for psychological management.

If the problem is of recent onset, explanation and reassurance are often sufficient. However, if the symptoms have been present for longer, reassurance is seldom enough, and repeated reassurance may lead to increasing requests for yet more removal of doubts. Keeping a diary to explore the relationship of symptoms to psychosocial causes can be more convincing than providing further explanation.

Further treatment should be based on the formulation of the patient’s individual problems. The treatment plan might include, for example, antidepressant medication, anxiety management, and cognitive therapy to change the patient’s inaccurate beliefs about the origin and significance of symptoms.

Much can usually be achieved by the primary care team and by the physicians using these basic procedures. However, chronic and recurrent problems may need to be referred to a psychiatrist or clinical psychologist for further treatment of associated psychiatric disorder, possibly involving cognitive therapy or dynamic psychotherapy. The psychiatrist can also help to coordinate any continuing medical care, especially when this involves several specialties and professions.

Box 15.1 Basic procedures for medically unexplained symptoms

1. Emphasize that the symptoms are real and familiar to the clinician.

2. Explain the role of psychosocial factors in all medical conditions.

3. Offer and discuss a psychosocial explanation of the symptoms.

4. Allow adequate time for the patient and their partner/family to ask questions.

5. Agree a treatment plan to include the following:

• treatment of any minor medical problem that is contributing to the symptoms

• treatment of any associated psychiatric disorder (commonly anxiety or depression)

• if appropriate, improvement of fitness by graded activity

• if appropriate, diary keeping to explore the relationship between symptoms and possible psychosocial causes.

Prognosis

The prognosis for less complex cases of fairly recent onset is good, but for chronic, multiple, or recurrent conditions it is much less so. For such cases the realistic goal may be to limit disability and requests for unnecessary medical investigation. Doctors need to recognize that they may also contribute to this process. Bensing and Verhaak (2006) have reviewed evidence from studies in primary care which demonstrate that doctors are as active in proposing biological explanations and tests as these patients are in asking for them.

For more detailed information about the management of medically unexplained symptoms, see Morriss and Gask (2009).

Chronic fatigue syndrome

Many terms have been used to describe this syndrome, the most prominent feature of which is chronic disabling fatigue—the terms include postviral fatigue syndrome, neurasthenia, and myalgic encephalomyelitis (ME). The descriptive term chronic fatigue syndrome (CFS) is now preferred. The diagnosis requires that the illness must have lasted for least 6 months, and that other causes of fatigue have been excluded (Fukuda et al., 1994).

Chronic fatigue syndrome has a long history. In the nineteenth century the symptoms were diagnosed as neurasthenia (Wessely, 1990), and in ICD-10 the syndrome can still be recorded in this way, an option that is widely chosen in China and some other countries. The diagnostic criteria for chronic fatigue syndrome overlap with those for a number of other psychiatric disorders, including depression, anxiety, somatoform disorders, and fibromyalgia. This syndrome remains a highly controversial disorder with a powerful lobby against any psychiatric interpretation. The persistence of this conflict exemplifies the problems that are encountered when defining these disorders.

Clinical features

The central features are fatigue at rest and prolonged exhaustion after minor physical or mental exertion. These features are accompanied by muscular pains, poor concentration, and other symptoms included in the list in Table 15.9. People with this condition are commonly most concerned to avoid activity. Frustration, depression, and loss of physical fitness are common.

Epidemiology

Surveys of the general population indicate that persistent fatigue is reported by up to 25% of the population at any one time. The complaint is common among people attending primary care and medical outpatient clinics. However, only a small proportion of people who complain of excessive fatigue meet the diagnostic criteria for chronic fatigue syndrome. Estimates of prevalence are around 0.5% of the general population, with a marked (20- to 40-fold) predominance of females (Prins et al., 2006).

Table 15.9 Case definition of chronic fatigue syndrome (Fukuda et al., 1994)

Inclusion criteria

Clinically evaluated, medically unexplained fatigue of at least 6 months’ duration that is:

• of new onset (not lifelong)

• not the result of ongoing exertion

• not substantially alleviated by rest

• a substantial reduction in previous level of activities

The occurrence of four or more of the following symptoms:

• subjective memory impairment

• sore throat

• tender lymph nodes

• muscle pain

• joint pain

• headache

• unrefreshing sleep

• post-exertional malaise lasting more than 24 hours

Exclusion criteria

• Active, unresolved, or suspected disease

• Psychotic, melancholic, or bipolar depression (but not uncomplicated major depression)

• Psychotic disorders

• Dementia

• Anorexia or bulimia nervosa

• Alcohol or other substance misuse

• Severe obesity

Aetiology

The aetiology of chronic fatigue syndrome is controversial. Suggested factors include the following:

1Biological causes. Several biological causes have been proposed, including chronic infection, immune dys-function, a muscle disorder, neuroendocrine dysfunction, and ill-defined neurological disorders. There is no convincing evidence for any of these causes, except infection, which may act as a precipitating factor.

2Psychological and behavioural factors. These appear to be important, especially concerns about the significance of symptoms, the resulting focusing of attention on symptoms, and avoidance of physical, mental, and social activities that worsen them. Many patients are depressed and/or anxious.

3Social factors. Stress at work is sometimes important. Belief that there must be a physical cause may be influenced by the stigma attached to a psychiatric diagnosis, and by some of the information provided by patient groups and practitioners.

An alternative approach to aetiology is to consider predisposing, precipitating, and perpetuating factors.

• Predisposing factors include a past history of major depressive disorder and perhaps personality characteristics such as perfectionism.

• Precipitating factors include viral infection and life stresses.

• Perpetuating factors may include neuroendocrine dys-function, emotional disorder, attribution of the whole disorder to physical disease, coping by avoidance, chronic personal and social difficulties, and misinformation from the media and other sources.

For further information, see Harvey and Wessely (2009). Chronic fatigue syndrome in children is considered on p. 664.

Course and prognosis

For established cases, the long-term outcome has been considered to be poor. However, it must be remembered that most of the studies of prognosis relate to patients referred to specialist centres, who may have experienced fatigue for a long time before the referral. Furthermore, most of the studies refer to prognosis before modern treatments (see below) were widely used.

Treatment

Many treatments have been suggested, but very few are of proven efficacy. There have been several randomized controlled trials of cognitive–behavioural therapy and of graded exercise regimes which have shown the benefits of these procedures over standard medical care alone, and over relaxation therapy (White et al., 2011).

Management

Assessment

As with all medically unexplained conditions, assessment should exclude treatable medical or psychiatric causes of chronic fatigue. It is important to enquire carefully about depressive symptoms, especially as the patient may not initially reveal them. Although extensive medical investigations are unlikely to be productive, the psychiatrist can usefully collaborate with a physician when assessing these patients. The formulation should refer to any relevant aetiological factors (see above).

Starting treatment

The six basic steps can be summarized as follows.

1. Acknowledge the reality of the patient’s symptoms and the disability associated with them.

2. Provide appropriate information about the nature of the syndrome for the patient and their family.

3. Present the aetiological formulation as a working hypothesis to be tested, not to be argued over.

4. treat identifiable depression and anxiety.

5. Encourage a gradual return to normal functioning by overcoming avoidance and regaining the capacity for physical activity.

6. Provide help with any occupational and other practical problems.

Medication

If there is definite evidence of a depressive disorder, anti-depressant drugs should be prescribed at the usual doses. Clinical experience suggests that selective serotonin reuptake inhibitors (SSRIs) are the best tolerated drugs in this context. Antidepressant drugs are also useful for reducing anxiety, improving sleep, and reducing pain. Low-dose tricyclic antidepressants may have a role here.

Psychological treatment

At the simplest level, these include education about the condition, and the correction of misconceptions about cause and treatment. Cognitive–behavioural methods include addressing misconceptions about the nature of the condition and excessive concerns about activity, and encouraging a gradual increase in activity. Associated personal or social difficulties can be addressed using a problem-solving approach.

For reviews of chronic fatigue syndrome, see Afari and Buchwald (2003) and Harvey and Wessely (2009).

Irritable bowel syndrome

Irritable bowel syndrome is characterized by abdominal pain or discomfort, with or without an alteration of bowel habits, that persists for longer than 3 months in the absence of any demonstrable disease.

Epidemiology

The condition occurs in as many as 10% of the general population (Wilson et al., 2004), the majority of whom do not consult a doctor.

Aetiology

The cause of the syndrome is uncertain, although there appears to be a disturbance of bowel function and sensation. Depressive and anxiety disorders are common among people who attend gastroenterology clinics with irritable bowel syndrome, especially among those who fail to respond to treatment.

Treatment

People with mild symptoms usually respond to education, reassurance about the absence of serious pathology, a change in diet and, when required, anti-motility drugs. More severe and chronic symptoms may need additional treatment. Cognitive–behavioural therapy has been shown to be of benefit, as to a lesser extent have tricyclic antidepressant drugs and SSRIs (Rahimi et al., 2008).

For a review of irritable bowel syndrome, see Mayer (2008).

Fibromyalgia

The term fibromyalgia refers to a syndrome of generalized muscle aching, tenderness, stiffness, and fatigue, often accompanied by poor sleep. A physical sign consisting of multiple specific tender points has been described, but it is probably non-specific. Women are affected more than men, and the condition is more common in middle age. The aetiology is uncertain, but there is a marked association with depression and anxiety. Controlled trials have shown the value of antidepressants (Hauser et al., 2009) and of behavioural interventions, especially those that include increased exercise (Sim and Adams, 2002).

For a review of fibromyalgia, see Mease and Choy (2009).

Factitious disorder

DSM-IV defines factitious disorder as the ‘intentional production or feigning of physical or psychological symptoms which can be attributed to a need to assume the sick role.’ The category is divided further into cases with psychological symptoms only, those with physical symptoms only, and those with both. In factitious disorder, symptoms are feigned to enable the person to adopt a sick role and obtain medical care (in malingering, symptoms are feigned to obtain other kinds of advantage; see below). The term Munchausen’s syndrome denotes an extreme form of this disorder (described below).

Epidemiology

The prevalence of factitious disorder is not known with certainty, but it accounts for about 1% of referrals to consultation–liaison services. The disorder usually begins before the age of 30 years. ‘Illness deception’ in physical disorder, covering both factitious disorder and malingering, is considered relatively common, albeit mild, in occupational health services, where one study (Poole, 2010) found it in 8% of consecutive attendees.

Aetiology

The cause is uncertain, in part because many affected individuals give histories that are inaccurate. There is often a history of parental abuse or neglect, or of chronic illness in early life with many encounters with the medical services, sometimes long periods in hospital, and sometimes alleged medical mismanagement. Previous substance misuse, mood disorder, and personality disorder are other common features. Many patients have worked in medically related occupations.

Prognosis

This is variable, but the condition is usually long-lasting. Few patients accept psychological treatment, but some improve during supportive medical care. In some cases there is evidence of other disturbed behaviours, including abuse of children and (on the part of those working in health professions) harm to patients.

Management

Assessment

When factitious disorder is suspected, the available information should be reviewed carefully, including the history given by informants as well as that provided by the patient. A psychiatrist may be able to assist in this assessment, and in cases of doubt further specialist medical investigation may be needed. Additional evidence may be obtained by careful observation of the patient, but the ethical and legal aspects of any proposal to make covert observations should be considered most carefully.

Starting treatment

When the diagnosis has been made, the doctor should explain to the patient the findings and discuss their implications. This should be done in a way that conveys an understanding of the patient’s distress and makes possible a discussion of potential psychosocial causes. Although some patients admit at this point that the symptoms are self-inflicted, others persistently deny this. One should not simply assume in this case that the patient is being deliberately misleading. Examining these patients (as with ‘fabulist’ patients) often yields a sense of self-deception where the process lies somewhere between conscious (fabulist) and unconscious processes. In these cases, management should still be directed to helping the patient to identify and overcome associated psychological and social difficulties, in the hope that improvement in such problems may be followed eventually by a lessening of the factitious disorder.

Staff who had been caring for the patient while the investigations were being performed may become angry when they discover that the patient has deceived them. Such feelings make management more difficult, and the psychiatrist should play a part in resolving them through discussion, and by explaining the nature and severity of the patient’s psychosocial problems. All closely involved staff should be involved in agreeing a treatment plan which defines what future medical care and what help with the associated problems is needed, both for the patient and for the family. Special risks and difficult ethical problems may arise when the patient is a healthcare worker (see Box 15.2).

For a review of factitious disorder, see Bass and Gill (2009).

Munchausen’s syndrome

Richard Asher suggested the term Munchausen’s syndrome for an extreme form of factitious disorder in which patients attend hospital with a false but plausible and often dramatic history that suggests serious acute illness (Asher, 1951). Often the person is found to have attended and deceived the staff of many other hospitals, and to have given a different false name at each of them. Many of these individuals have scars from previous (negative) exploratory operations.

People with this disorder may obstruct efforts to obtain information about them, and some interfere with diagnostic investigations. When further information is obtained, especially that about previous hospital attendance, the patient often leaves. The aetiology and long-term outcome of this puzzling disorder are unknown.

Factitious disorder by proxy

In 1977, Roy Meadow observed two cases of mothers apparently deliberately misleading doctors about their child’s health. He went on to describe a form of child abuse in which parents (or other carers) give false accounts of symptoms in their children, may fake or deliberately induce signs of illness, and seek repeated medical investigations and needless treatment for the children (Meadow, 1985).

Box 15.2 Healthcare workers with factitious disorder

Highly publicized cases of serious physical harm to patients caused by a small number of healthcare workers with factitious disorder, or by those producing fictitious disorder by proxy, have aroused great public concern. It is essential, therefore, in the management of these patients to consider the risk to others if the patient continues to work in healthcare.

These infrequent cases can present difficult medico-legal problems. If the diagnosis is in doubt, it may be judged necessary to seek additional evidence by searching the patient’s belongings for items (e.g. needles or medication) that could have been used to simulate symptoms. In general it is unethical to search patients’ belongings without first explaining the reason for this and obtaining their permission. If the patient refuses to be searched, and there is a serious risk to others should the diagnosis be missed, it is usually appropriate to obtain advice from one or more experienced professionals, including a medico-legal opinion. Advice may also be needed when judging risk and, if the risk is serious and the patient refuses to allow discussion with the employers, when deciding whether to breach confidentiality.

The signs most commonly reported are neurological signs, bleeding, and rashes. Some children collude in the production of the symptoms and signs. The perpetrators usually have severe personality disorder, and some have a factitious disorder themselves. Hazards for the children include disruption of education and social development. The prognosis is probably poor for both children and perpetrators, and there is a significant mortality (Sheridan, 2003). Occasional cases of murder of children by professional carers have been described as an extreme form of this disorder; some of these people had factitious disorder (see Box 15.2).

The condition is rare, and diagnosis should be made with great caution and only after the most careful investigation. In the UK, a number of high-profile legal cases have highlighted the danger of diagnosis on insufficient positive evidence and without adequate exclusion of other causes of the child’s symptoms.

Malingering

Malingering is not a medical diagnosis but a description of behaviour. The term denotes the deliberate simulation or exaggeration of symptoms for the purpose of obtaining some gain, such as financial compensation. The distinction from factitious disorder and from somatoform disorder can be difficult, because it requires an accurate understanding of the person’s motives.

Malingering is infrequent, and is most often encountered among prisoners, the military, and people seeking compensation for accidents. Several kinds of clinical picture have been described:

• malingered medical conditions and disability

• malingered psychosis, seen in those who wish to obtain admission to hospital for shelter, or to prolong their stay in hospital, and in criminal defendants who are trying to avoid standing trial or to influence sentencing

• malingered or exaggerated post-traumatic stress disorder

• malingered cognitive deficit.

Ganser’s syndrome (see p. 404) is thought by some to be a form of malingering.

Assessment

Assessment depends on careful history taking and clinical examination, and close observation for discrepancies in the person’s behaviour. Lawyers or insurers sometimes use surveillance by video or other means to detect the behaviour but, for ethical reasons, clinicians seldom do so. Psychological tests have been used to aid detection, but none of these has proven validity.

Management

If malingering is certain, the patient should be informed tactfully and their situation discussed non-judgement-ally. They should be encouraged to deal more appropriately with any problems that led to the behaviour, and in appropriate cases offered some brief face-saving intervention as a way to give up the symptoms.

For a review of malingering, see Eastwood and Bisson (2008).

Somatoform and dissociative disorders

Somatoform and dissociative disorders are considered together in this chapter because they are classified together in DSM-IV. Apart from this, the disorders are not closely linked. Some of the terms used are defined in Box 15.3.

Box 15.3 Some definitions

Somatoform disorders. A generic term used in DSM to denote a group of disorders characterized by physical symptoms that are not explained by organic factors.

Dissociation. A hypothetical mechanism whereby psychological processes relating to consciousness are split or fragmented. Dissociation is discussed further in Chapter 8.

Dissociative symptoms. Symptoms that have been thought to arise through the mechanism of dissociation.

Conversion. A term introduced by Freud to denote a hypothetical mechanism by which psychological stress leads to (i.e. is converted into) physical symptoms.

Conversion disorder. Any condition that may result from conversion; conditions that in the past were called hysteria.

Classification

In DSM-IV, the overall term somatoform disorder is used to denote a group of conditions (listed in Table 15.10) characterized by physical symptoms that occur without an adequate physical cause. In ICD-10, these disorders are not allocated a separate category; instead they are classified as members of a wider category of neurotic, stress-related, and somatoform disorders.

A further, potentially confusing difference between the classifications is that in ICD-10 the condition is called conversion disorder, whereas in DSM-IV it is a member of a group called dissociative disorders, while in DSM-IV conversion disorder is classified as a somato-form disorder. We follow the DSM-IV convention (see Table 15.10).

Somatoform disorder

This section is concerned only with the groups of unexplained physical symptoms that are classified within the somatoform disorder category. The disorder was introduced as a provisional diagnostic category in DSM-III, and many years later its value is still uncertain. The defining feature is the presence of: physical symptoms suggesting a physical disorder for which there are no demonstrable organic findings or known physiological mechanisms, and for which there is strong evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts.

Table 15.10 Categories of somatoform disorders in disorders in ICD-10 and DSM-IV

Images

Many people experience such symptoms, which are associated with significant distress and disability (Bass et al., 2001). However, there is doubt about the value of grouping together, under this one rubric, conditions which are dissimilar in many ways and which overlap (are comorbid) with anxiety disorders and depressive disorders (Sharpe and Mayou, 2004). Also, two of the conditions—hypochondriasis and somatization disorder—are so enduring that it has been suggested that they should be classified as personality disorders.

Classification in DSM-IV and ICD-10

Although there are broad similarities, there are also three important differences between the categories in DSM-IV and ICD-10 (see Table 15.10).

• Neurasthenia is not included in DSM-IV because the category is seldom used in the USA (despite being first popularized there by George Beard, and being called for a time ‘the American neurosis’). It is included in ICD-10 because this is an international classification and the category is used in some Far Eastern counties.

• Conversion disorder is a somatoform disorder in DSM-IV but not in ICD-10 (see above).

• Body dysmorphic disorder does not exist as a separate category in ICD-10; instead it is included in the diagnostic criteria for hypochondriacal disorder.

There are also problems which both classifications share:

• Diagnostic criteria within the group are based on a mixture of principles—aetiology, symptom count, consultation, and response to medical treatment.

• Diagnostic criteria for hypochondriacal disorder were derived largely from patients attending hospitals, and do not apply readily to many of the people with unexplained symptoms in the community.

• Many cases in the community do not meet the diagnostic criteria for any specific somatoform disorder, and have to be placed in one of the two non-specific categories of undifferentiated somatoform disorder or other somatoform disorders. These residual categories have attracted little research, and their diagnostic criteria are so broad that almost all persistent unexplained physical symptoms can be included within them.

• The seemingly small differences between DSM-IV and ICD-10 criteria have resulted in large differences in estimates of the prevalence of somatoform disorder as a whole, and of the subcategories (Simon, 2009).

A revision of this classification is daunting, and Shedler et al. (2010) have suggested a multidimensional description in terms of clinical syndrome, duration, number of symptoms, cognitions, and associated psychiatric disorder.

Conversion disorder

Conversion disorder is the term used in DSM to replace the older term hysteria; it is the equivalent of dissociative (conversion) disorder in ICD-10. The term refers to a condition in which there are isolated neurological symptoms that cannot be explained in terms of known mechanisms of pathology, and in which there has been a significant psychological stressor. The study of such symptoms has a long history. Some understanding of this history is a necessary background to knowledge of the present status of the concept of conversion disorder (see Box 15.4). The evolution of thinking about hysteria is important for Freud’s ideas, which have greatly influenced twentieth-century psychiatry.

Clinical features

In DSM-IV, conversion disorder is divided into four subtypes:

1with motor symptom or deficit: this includes such symptoms as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or ‘lump in throat’, aphonia, and urinary retention

Box 15.4 A brief history of hysteria

There are descriptions of hysteria in ancient Greek medical texts. The disorder was thought to result from abnormalities of position or function of the uterus (hence the name). This view persisted until the seventeenth century. Gradually, the idea became accepted that hysteria is a disorder of the brain, and by the nineteenth century the importance of predisposing constitutional and organic causes was recognized. It was also accepted that the usual provoking cause was strong emotion.

In the later years of the nineteenth century, the studies of hysteria by Jean-Martin Charcot, a French neurologist working at the Salpêtrière Hospital in Paris, were particularly influential. Charcot believed at first that the symptoms of hysteria were caused by a functional disorder of the brain, and that this disorder also rendered patients susceptible to hypnosis. As a result of this susceptibility, new symptoms could be induced in these patients by suggestion, and existing ones could be modified. Later, Charcot became interested in the idea of his former pupil, Pierre Janet, that the basic disorder in hysteria is not suggestibility but a tendency to dissociation. By this Janet meant that the patient had lost the normal integration between various parts of mental functioning (see also p. 401), and that this did not require a prior organic lesion—anyone could be hypnotized. Janet believed that this dissociation led to a loss of awareness of certain aspects of psychological functioning that would otherwise be within awareness. Janet’s ideas were influential for a while, but never had the impact of those of Freud. For a review of Janet’s ideas about hysteria, see van der Kolk and van der Hart (1989).

Freud visited Charcot in the winter of 1895–96 and was impressed by demonstrations of the susceptibility of patients to hypnosis, and of the power of suggestion. On his return to Vienna, Freud and his colleague Josef Breuer studied patients with hysteria and published their findings in the seminal monograph Studies on Hysteria (1893–95). They proposed that hysteria was caused by emotionally charged ideas, usually sexual in nature, which had become lodged in the patient’s unconscious mind as a result of some past experience, and which were excluded from conscious awareness by repression (see p. 155). Freud adopted the word ‘conversion’ to refer to the hypothetical process whereby this hidden, unexpressed emotion was transformed into physical symptoms. He summarized this idea in the phrase ‘hysterics suffer mainly from reminiscences.’

In the years that followed, Freud came to believe that this original formulation was incorrect and had been based on fabricated accounts (‘screen memories’), and from then on he wrote no more on hysteria. Hysteria was thought to be a declining problem in developed countries, and the erroneous view that many apparent cases were in fact unrecognized organic disease was proposed vigorously by Slater (1965). Subsequent changes of opinion are considered on p. 396.

For an account of the history of hysteria, see Shorter (1992). For an account of the history of the concept of conversion, see Mace (2001).

2with sensory symptom or deficit: this includes such symptoms as loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations

3with seizures or convulsions: this includes seizures or convulsions with voluntary motor or sensory components

4with mixed presentation: symptoms of more than one category are evident.

Conversion symptoms do not normally reflect the appropriate physiological or pathological mechanisms. They are also highly responsive to suggestion, and may vary considerably in response to the comments of other people, especially doctors. Symptoms may be ‘reinforced’ by measures such as providing a wheelchair for the patient who has difficulty walking. Patients with conversion disorders may seem surprisingly unconcerned about the nature and implications of the symptoms (‘ belle indifference’). However, this belle indifference is not invariable.

The original psychoanalytical understanding focused on the concepts of primary and secondary gain. Secondary gain implies a significant external benefit or avoidance of unwanted responsibilities, as a result of the symptoms. Primary gain refers to the relief obtained by the conversion of the mental distress generated by a hypothesized neurotic conflict into physical symptoms, thereby allowing the conflict to remain unconscious. Secondary gains are common in many psychiatric and physical disorders, but are often very prominent in conversion disorders.

Epidemiology

The prevalence of conversion disorder in the general population is difficult to determine. Estimates vary according to the criteria used and the population studies. A review of five studies indicated an incidence rate of 5–12 per 100 000 per annum, with the lowest rates in a study of psychiatric practice, consistent with the view that many of these patients are not referred to psychiatrists. Estimates of prevalence vary even more, but are generally around 50 per 100 000. The few studies that have examined change over time do not support the belief that the condition is disappearing (Akagi and House, 2002).

Aetiology

The aetiology is unknown, and this is reflected in the wide range of theories with few research findings to support them.

• Psychodynamic theories use the explanatory concept of conversion of emotional distress into physical symptoms which often have a symbolic meaning.

• Social factors appear to be major determinants of the onset and development of conversion symptoms.

• Neurophysiological mechanisms: functional neuroimaging has yielded results which are compatible with the idea of malfunctioning of the normal interactions between regions of the brain concerned with the intention to move and those involved in the initiation of movement (Athwal et al., 2001).

• Cognitive explanations: R. J. Brown (2002) suggested that the symptoms are caused by the chronic activation of representations of the symptoms stored within memory, the process being driven by attention directed to these representations.

• Cultural explanations: some of the phenomena classified as conversion disorder in Western countries may, in some other cultures, be accepted as possession states (see section on trance and possession disorders, p. 404).

Prognosis

Prognosis for subsequent neurological disorder

Due to the limited numbers of studies and their high heterogeneity, there is a lack of rigorous empirical evidence to identify relevant prognostic factors in patients who present with persistent medically unexplained symptoms. However, it seems that a more serious condition at baseline is associated with a worse outcome (Olde Hartman et al., 2009).

Most of the patients who are seen in general practice or hospital emergency departments with conversion disorders of recent onset recover quickly. Disorders that last for longer than a year are likely to persist for many years. Slater’s widely cited follow-up described the development of a physical and psychiatric disorder in a high proportion of patients (Slater, 1965). Slater’s sample was highly atypical even for his tertiary clinic. A more recent follow-up of patients attending the same hospital found a very low incidence of physical or psychiatric diagnoses. A recent review has demonstrated that misdiagnosis has steadily declined over the last few decades, and is now only about 4% (Stone et al., 2005). When the diagnosis of conversion disorder was made, it remained stable over time.

Prognosis for subsequent psychiatric disorder

Although subsequent neurological disorder is uncommon in these patients, psychiatric morbidity is high. Usually the psychiatric symptoms are present when the patient is first seen.

Predictors of prognosis

Predictors of a good outcome are a short history and young age; predictors of a poor outcome are a long history, personality disorder, and receipt of disability benefit or involvement in litigation (Ron, 2001).

Box 15.5 Treatment of acute conversion disorder

• Obtain a medical and psychiatric history from the patient and from informants.

• Carry out appropriate medical and psychiatric examination and arrange investigations for physical causes.

• Reassure the patient that the condition is temporary, well recognized and, in the case of motor disorders, due to a problem in converting intention into action.

• Avoid reinforcing symptoms or disability.

• Offer continuing help with any related psychiatric or social problems.

Treatment

For acute conversion disorders seen in primary care or hospital emergency departments, reassurance and suggestions about improvement are often sufficient, together with immediate efforts to resolve any stressful circumstances that may have provoked the reaction (see Box 15.5). The doctor should be sympathetic and positive, and provide a socially acceptable opportunity for a rapid return to normal physical functioning (e.g. by arranging a brief course of physiotherapy). The patient should feel that the problem is accepted as deserving assessment, that it is common, and that a good outcome can be expected. The therapist should discuss any personal difficulties that have been identified, and suggest that they deserve attention in their own right.

Where symptoms have persisted for more than a few weeks, more elaborate treatment is required. The general approach is to focus on removing any factors that are reinforcing the symptoms and disability, and on encouraging normal behaviour. It should be explained that the symptoms and disability (as in remembering, or moving their arm) are not caused by physical disease but by an inability to convert willed intention into action, and that sensory problems are caused by an inability to become aware of sensory information, not by a lesion interfering with sensory pathways. This problem is provoked by psychological factors. The patient should also be told that they can regain control of the disturbed function and, if necessary, they should be offered help to do so—usually through physiotherapy. Psychotherapists often describe this as providing ‘a license for change.’

Attention is then directed away from the symptoms and towards the problems that have provoked the disorder. Staff should show concern for the patient, but at the same time should encourage self-help. They should not make undue concessions to the patient’s disability—for example, a patient who cannot walk should be encouraged to walk again, rather than being provided with a wheelchair. A supportive and sympathetic approach should be used that does not appear in any way uncaring or punitive. To achieve this end, there must be a clear plan so that all members of staff adopt a consistent approach to the patient.

Medication has no direct part to play in the treatment of these disorders. However, if a conversion disorder is secondary to a depressive or anxiety disorder, treatment of the primary condition usually leads to improvement in the secondary symptoms. Cognitive–behaviour therapy appears to be of little specific value, although it may act as a non-specific aid to recovery.

It is essential that measures to reduce symptoms are accompanied by help with any associated personal and social difficulties. Brief and focused psychological treatments are helpful, but more intensive therapy may result in transference reactions which are difficult to manage.

Patients who do not improve should be reviewed thoroughly for undiscovered physical illness. All patients, whether improved or not, should be followed carefully for long enough to exclude any organic disease that might have been missed at the original assessment.

‘Epidemic hysteria’

Occasionally, dissociative (or conversion) disorder spreads within a group of people as an ‘epidemic.’ This most often happens in closed groups of young women—for example, in a girls’ school, a nurses’ home, or a convent. Often anxiety has been heightened by some fear of an epidemic of disease present in the neighbourhood. Typically, the epidemic starts in one person who is highly suggestible, histrionic, and a focus of attention in the group. Gradually, other cases appear, first in the most suggestible individuals, and then spreading to the others. The symptoms are variable, but fainting and dizziness are common. Outbreaks among schoolchildren have been documented.

Somatization disorder

The core feature of somatization disorder is multiple somatic complaints of long duration, beginning before the age of 30 years. In 1962, psychiatrists in St Louis (Perley and Guze, 1962) described a syndrome of chronic multiple somatic complaints without any identified organic cause, which they regarded as a form of hysteria. They named it Briquet’s syndrome after a nineteenth-century French physician who wrote a monograph on hysteria.

A similar syndrome was introduced in DSM-III. The diagnostic criteria were highly restrictive, but in DSM-IV the criteria were relaxed. They require four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudo-neurological symptom, none of which is fully explained by a medical condition. The ICD-10 criteria require at least six symptoms relating to at least two organ systems from among a list of 14 predefined symptoms distributed in four groups—gastrointestinal, cardiovascular, neurogenital, and skin or pain symptoms.

Epidemiology

The reported prevalence of somatization disorder depends on the assessment methods used. Community surveys have reported prevalence values of less than 1%, while those in primary care have usually been in the range 1–2%. The disorder is twice as common in women as in men. There is substantial comorbidity with other psychiatric disorders, such as major depression. The diagnosis is considerably less stable over time than was suggested in the original description. For a review, see Simon (2009).

Aetiology

The St Louis group reported a familial association between somatization disorder in females and sociopathy and alcoholism in their male relatives. They concluded that it was a unitary syndrome, which was stable over time, but this has not been confirmed.

Treatment

Treatment is difficult and patients often consume large amounts of resources. Continuing care by one doctor using only the essential investigations can reduce the use of health services and may improve the patient’s functional state (Smith, 1995). Psychiatric assessment can help to clarify a complicated history, to negotiate a simplified pattern of care, and to agree the aims of treatment with the patient, the family, and the responsible physician. The aim of treatment is more often to limit further progression than to cure. For a review, see Kroenke et al. (2009).

Undifferentiated somatoform disorder

This is a residual category for unexplained physical symptoms, lasting at least 6 months, which are below the threshold for a diagnosis of somatization disorder. Its prevalence is much higher than that of somatization disorder. Since the data do not show any clear boundary between the two conditions, based on the number or distribution of unexplained symptoms, it has been suggested that the criteria for somatization disorder should be made less restrictive. The problem would remain, however, of defining syndromes by an arbitrary number of unexplained symptoms when research suggests that there is a continuum (Mayou et al., 2003).

Hypochondriasis

The term hypochondriasis is one of the oldest medical terms, originally used to describe disorders believed to be due to disease of the organs situated in the hypochondrium. It is now defined by DSM-IV and ICD-10 in terms of conviction and/or fear of disease that is unsupported by the results of appropriate medical investigation. DSM-IV describes the condition as a:

preoccupation with a fear or belief of having a serious disease based on the individual’s interpretation of physical signs or sensations as evidence of physical illness. Appropriate physical evaluation does not support the diagnosis of any physical disorder that can account for the physical signs or sensations or for the individual’s unrealistic interpretation of them. The fear of having, or belief that one has a disease, persists despite medical reassurance.

The criteria exclude patients with panic disorder or delusions, and require that symptoms have been present for at least 6 months. There is continuing uncertainty about the status of similar conditions that last for less than 6 months, whether there is a hypochondriacal personality disorder, and whether illness phobias should be included in the category.

Epidemiology

Attempts to estimate prevalence have been hindered by the absence of standardized assessment. Although some primary care surveys have estimated a prevalence of around 5%, the World Health Organization multicentre primary care survey (Gureje et al., 1997) found a prevalence of 0.8%, or 2.2% using a less restrictive definition. This later definition omitted the criterion ‘persistent refusal to accept medical reassurance’, but retained the triad of illness worry, associated distress, and medical help-seeking. Comorbidity with depression and anxiety disorders is frequent. For a review of epidemiology, see Simon (2009).

Prognosis

Evidence about course and prognosis is limited. A review of medically unexplained symptoms, somatization, and hypochondriasis (Olde Hartman et al., 2009) failed to find prognostic factors other than severity of disorder at baseline associated with a worse outcome.

Aetiology

The cause is unknown. Cognitive formulations suggest that there is faulty appraisal of normal bodily sensations which are interpreted as evidence of disease. Misinterpretation is maintained by continually seeking reassurance and examining or rubbing the supposedly affected part.

Treatment

Since the disorder is chronic or recurrent, management is difficult. Care should be exercised to ensure that a hypo-chondriacal presentation of depression is not missed and left untreated. Repeated reassurance is unhelpful and may prolong the patient’s concerns. Investigations should be limited to those indicated by the medical priorities, and not extended to satisfy the patient’s demands. Misinterpretations of the significance of bodily sensations should be corrected, and encouragement given to find constructive ways of coping with symptoms. Trials have shown more benefit for hypochondriacal symptoms from cognitive–behavioural treatment than from short-term dynamic psychotherapy or routine medical care (Sørensen et al., 2011). Poor response is predicted by greater psychopathology and higher social impairment (Hiller et al., 2002).

For a general review of hypochondriasis, see Noyes (2009).

Body dysmorphic disorder

Body dysmorphic disorder is the DSM term for a subgroup of the broader but ill-defined syndrome of dysmor-phophobia, which was first described by Morselli (1886) as ‘a subjective description of ugliness and physical defect which the patient feels is noticeable to others.’ In DSM the term body dysmorphic disorder denotes dysmor-phophobia that is not better accounted for by another psychiatric disorder. The preoccupation with the imagined defect in appearance is usually an overvalued idea, but individuals ‘can receive an additional diagnosis of delusional disorder, somatic type.’ The syndrome overlaps with delusional disorder (see Chapter 12), hypochondriasis, and obsessive–compulsive disorder. In ICD-10 the condition is a subgroup of the broader category of hypochondriasis.

Patients with dysmor-phophobia are convinced that some part of their body is too large, too small, or misshapen. To other people the appearance is normal, or there is a trivial abnormality. In the latter case it may be difficult to decide whether the preoccupation is disproportionate. The most common concerns are about the nose, ears, mouth, breasts, buttocks, or penis, but any part of the body may be involved. The patient may be constantly preoccupied with and tormented by their mistaken beliefs. It seems to them that other people notice and talk about the supposed deformity. They may blame all their other difficulties on it—if only their nose/breasts were a better shape, they would be more successful in their work, social life, or sexual relationships. Time-consuming behaviours which aim to re-examine, improve, or hide the perceived defect are frequent. Social impairment is considerable. There is substantial comorbidity, especially with major depression and social phobia.

The condition usually begins in adolescence. It is chronic, although it often fluctuates over time. It is probable that there is some improvement over a period of many years, but there have been no long-term prospective studies.

The severe cases described in the psychiatric literature are infrequent, but less severe forms of dysmor-phophobia are more common, especially among those seeking plastic surgery or consulting dermatologists. As with the more severe cases, many meet the diagnostic criteria for other disorders.

Assessment

Assessment should include questions about the nature of the preoccupations with appearance and about the ways in which this has interfered with the patient’s personal and social life. Diagnosis can be difficult because some sufferers fail to reveal the precise nature of their symptoms due to embarrassment. This failure may result in misdiagnosis as social phobia, panic disorder, or obsessive–compulsive disorder.

Treatment

When body dysmorphic disorder is secondary to a psychiatric disorder such as major depression, the latter should be treated in the usual way. The treatment of primary body dysmorphic disorder is often difficult. It is essential to establish a working relationship in which the patient feels that the psychiatrist is sympathetic, understands the severity of the problems, and is willing to help. Since many patients will be requesting surgery, it is important to explain the lack of success of this approach and suggest that there are other effective treatments. There is some modest support for the use of SSRIs (Phillips, 2008), but little for cognitive–behaviour therapy (Ipser et al., 2009). Counselling and practical help should be provided for any occupational, social, or sexual difficulties that accompany the condition. Although some patients are helped by this approach coupled with continued support, many are not.

Cosmetic surgery is often successful for patients with conditions other than dysmor-phophobia. However, surgery is usually contraindicated for people who have body dysmorphic disorder, many of whom are very dissatisfied after the operation. Selection for surgery therefore requires careful assessment of the patient’s expectations. Those with the most unrealistic hopes generally have poorer prognoses. Assessment is difficult, and collaboration between plastic surgeons, psychiatrists, and psychologists is valuable. Unintended rebuffs by surgeons or psychiatrists can increase the difficulties of management.

Somatoform disorder not otherwise specified

This residual diagnostic category is used for a wide range of somatoform symptoms that do not meet the criteria for the specific somatoform categories discussed so far, or for adjustment disorder with physical complaints.

Somatoform pain disorder

This term denotes patients with chronic pain that is not caused by any physical or specific psychiatric disorder. DSM-IV states that the essential feature of this disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to cause distress or impairment of functioning, and that neither organic pathology nor a pathophysiological mechanism has been found to account for it. Alternatively, when there is related organic pathology, the pain or resulting social or occupational impairment is grossly in excess of what would be expected.

Epidemiology

Pain is widely reported in surveys of the general population. Most people report pain that is transient, but a minority describe persistent or recurrent pain leading to disability (Gureje et al., 1998). Pain is the most common symptom among people who consult doctors. Acute pain usually has an organic cause, but psychological factors can affect the subjective response to pain irrespective of the main cause.

In general practice, pain is a common presenting symptom of emotional problems. In psychiatric practice, it has been reported that pain is experienced by about 20% of inpatients and over 50% of outpatients. Pain is particularly associated with depression, anxiety, panic, and somatoform disorders. Patients with multiple pains are especially likely to have associated psychiatric disorder (Gureje et al., 1998).

Aetiology

Chronic pain occurs in many conditions, including neurological or musculoskeletal disorders. It often has both physical and psychological causes. A ‘pain-prone disorder’ has been suggested as a variant of depressive disorder, but there is little evidence for this (Von Korff and Simon, 1996). It is more likely that in these cases the pain arises from personal and social factors, and that beliefs about pain are important in maintaining it (Linton, 2000). Chronic pain may impose great burdens on the patient’s family. The attitude of family members and other caregivers can also influence the perception of pain, its course, and the response to treatment.

Assessment

The assessment of a patient who is complaining of pain of unknown cause should include the following:

• thorough investigation of possible physical causes: when the results of this investigation are negative, it should be remembered that pain may be the first symptom of a physical illness that cannot be detected at an early stage

• afull description of the pain and the circumstances in which it occurs

• asearch for symptoms of a depressive or other psychiatric disorder

• adescription of pain behaviours—for example, the presentation of symptoms, requests for medication, and responses to pain

• the patient’s beliefs about the causes of pain and its implications.

Treatment

The management of chronic pain should be individually planned, comprehensive, and involve the patient’s family. Skill is required to maintain a working relationship with patients who are unwilling to accept an approach that uses psychological treatments as part of the treatment of pain. Any associated physical disorder should be treated and adequate analgesics provided. The treatment of pain associated with a psychiatric disorder is the treatment of the primary condition.

Psychological care is directed towards the following:

• Assessment of any associated mental disorder. This assessment should be made on the basis of positive findings, and not solely because no specific organic cause has been identified. If depressive illness is present it should be treated vigorously. Tricyclic antidepressant medication is effective in some patients with chronic pain even without evidence of a depressive disorder (O’Malley et al., 1999).

• Assessment of whether psychological techniques are indicated to modify the pain or any associated behaviours. Cognitive–behavioural treatment aims to encourage the use of distraction, relaxation, and other ways of coping with the pain, and to reduce social reinforcement of pain-related behaviour. In a meta-analysis these treatments had a significant although modest effect (Eccleston et al., 2009).

Multidisciplinary pain clinics bring together expertise in somatic and psychological treatments for pain.

For a review of psychological approaches to chronic pain, see Bass and Jack (2002).

Some specific pain syndromes

Many kinds of pain are common in the population. This section is concerned with headache, facial pain, back pain, and pelvic pain.

Headache

Patients with chronic or recurrent headache are sometimes referred to psychiatrists. There are many physical causes of headache, notably migraine, which affects about one in ten of the population at some time in their life. Many patients who attend neurological clinics have headaches for which no physical cause can be found. The commonest of these is ‘tension’ headache, which is usually described as a dull generalized feeling of pressure or tightness extending around the head. It is frequently of short duration and is relieved by analgesia or a good night’s sleep, but may occasionally be constant and unremitting. Some patients describe depressive symptoms, and others describe anxiety in relation to obvious life stresses. Psychological factors seem to contribute to aetiology, but there is no evidence that the headaches result from increased muscle tension, and vascular mechanisms are more likely.

Most patients with headaches for which no physical cause can be found are reassured by an explanation of the negative results of investigations. Antidepressants and stress management both produce modest improvement (Holroyd et al., 2001).

Facial pain

Facial pain has many physical causes. In addition, there are at least two forms in which psychological variables appear to be important. The more common of these is temporomandibular dysfunction (Costen’s syndrome or facial arthralgia). This is characterized by a dull ache around the temporomandibular joint, and the condition usually presents to dentists. ‘Atypical’ facial pain is a deeper aching or throbbing pain which is more likely to present to neurologists. Patients with either of these symptoms are often reluctant to see a psychiatrist, but several trials suggest that some antidepressants can relieve symptoms even when there is no evidence of a depressive disorder. Cognitive–behaviour therapy has been found to enhance the effect of usual dental care for temporomandibular disorders (Litt et al., 2009).

For a review of the psychological aspects of facial pain, see Feinmann (1999).

Back pain

Back pain is the second leading cause of visits to primary-care doctors, and a major cause of disability. Most acute pain is transient, but in about 20% of patients it persists for more than 6 months. Psychological and behavioural problems at the onset predict a poor outcome (Linton, 2000). Treatment includes the provision of accurate information about the cause and outcome of the condition, limited use of analgesics, and a graded increase in activity. Von Korff et al. (1994) reported that, in primary care, systematic advice about self-care led to a functional outcome as good as that achieved with analgesia and bed rest, incurred less cost, and was more satisfactory to patients. A Cochrane review found that behavioural treatment had some effect, but did not add significantly to the effect of the usual treatment programmes for chronic low back pain (van Tulder et al., 2002). Two recent reviews concluded that antidepressants had no effect in reducing back pain (Urquhart et al., 2008; Kuijpers et al., 2011), but a more general review of chronic pain (including low back pain) concluded that they may help as part of a broader intervention (Kroenke et al., 2009).

Chronic pelvic pain

Pelvic pain is one of the most common symptoms reported by women attending gynaecology clinics. The pain often persists despite negative investigations, and psychological factors appear to be significant causes of the pain and the disability.

Dissociative disorders

In DSM-IV, the essential feature of dissociative disorders is a disruption of the usually integrated functions of consciousness, memory, identity, or perception. This disturbance may be sudden or gradual, transient or chronic.

Dissociation is a crucial concept in the development of psychiatry, and a history of the term is reviewed briefly in Box 15.6.

Types of dissociative disorder

Dissociative disorders are the conditions listed in Table 15.11 together with the corresponding terms in ICD-10. The inclusion in ICD-10 of the bracketed term conversion in the title of the group reflects the previous convention of classifying these conditions with the conversion disorders.

Box 15.6 A brief history of dissociation

The term dissociation is associated in particular with the French philosopher and psychiatrist, Pierre Janet (1859–1947), who worked for a time with Jean-Martin Charcot at the Salpêtrière Hospital in Paris. He studied aspects of sensory perception and mental integration in hysteria and other neuroses, and used the term désagregation psychologique (translated as dissociation) to describe the breakdown of this integration. For a while Janet’s ideas were influential (see van der Kolk and van der Hart, 1989). However, his theories were overshadowed by those of Freud.

In the 1970s, interest in dissociation revived as a result of studies of the effects of psychological trauma, especially among Vietnam War veterans. These studies documented symptoms occurring in response to traumatic events, and suggested a common origin in the mechanism of dissociation, a new name, dissociative symptoms (see Table 15.11), and a new diagnostic category of dissociative disorders.

Some authors consider that these disorders are well established and common (e.g. Coons, 1998), while others doubt the evidence base both for the category and for its constituents (Merskey, 2000).

Table 15.11 DSM-IV classification of dissociative disorder and their ICD-10 equivalents

Images

Dissociative amnesia

The essential feature of dissociative amnesia is an inability to recall important personal memories, usually of a stressful nature, that is too extensive to be accounted for by normal forgetfulness. Dissociative amnesia may occur either alone or during the course of other dissociative disorders and of post-traumatic stress disorder, acute stress disorder, and somatization disorder. The diagnosis is made only when these other conditions are not present.

Dissociative amnesia must be distinguished from amnesia that has a medical cause. It has been described in two forms:

1. circumscribed amnesia for a single recent traumatic event

2. inability to recall long periods of childhood; among patients who present in this way, some have concurrent organic disease.

For a review, see Coons (1998).

Dissociative fugue

This condition is extremely rare. In a dissociative fugue there is loss of memory coupled with wandering away from the person’s usual surroundings. Affected individuals usually deny all memory of their whereabouts during the period of wandering, and some deny knowledge of their personal identity. Many dramatic case histories have been published (see Hacking, 1998). The disorder must be distinguished from organic disorder, including epilepsy and substance intoxication.

Dissociative identity disorder

In this disorder (widely known by the ICD-10 term multiple personality disorder) there are sudden alternations between two patterns of behaviour, each of which is forgotten by the patient when the other is present. One pattern is the person’s normal personality, while the other ‘personality’ is an integrated array of emotional responses, attitudes, memories, and social behaviour, which contrasts—often strikingly—with the normal personality. Sometimes there is more than one additional ‘personality.’ The criteria for the DSM-IV diagnosis are listed in Box 15.7. The condition is probably rare, but it has been reported more frequently in certain historical periods, notably around the end of the nineteenth century (Hacking, 1998). These variations over time probably reflect the changing interests of doctors rather than true changes in prevalence. In the course of the last 40 years there has been another increase in the number of reported cases, especially in the USA. It is not certain whether this change is real, and epidemiological studies do not provide the answer because they report such widely varying prevalence rates. The disorder has been highly controversial and, along with the associated ‘recovered memory syndrome’, generates fierce debate and legal challenges.

Patients who meet the criteria in Box 15.7 often meet the criteria for other diagnoses, including schizophrenia, personality disorder, and substance abuse. Many also have symptoms of anxiety and depression. The relationship between dissociative identity disorder and these other conditions would be clarified by long-term follow-up studies, but no systematic studies of this kind have been reported.

Two issues have dominated the discussion of aetiology:

1The role of severe trauma. Clinical experience and research have found that many individuals who have the disorder describe severe physical or sexual abuse taking place during childhood. It has been suggested that dissociation began as a psychological defence mechanism that reduced distress at the time of the original trauma, but had unfortunate lasting consequences.

2Iatrogenic factors. It has been argued that the widespread publicity given to some people with multiple personality, the credulity of some therapists, and the use of hypnosis have been responsible for at least some instances of the disorder. For a review, see Putnam and Loewenstein (2000). For a sceptical opinion, see Piper and Merskey (2004a,b).

Box 15.7 DSM-IV diagnostic criteria for dissociative identity disorder

A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).

B. At least two of these identities or personality states recurrently take control of the person’s behaviour.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g. blackouts or chaotic behaviour during alcohol intoxication) or a general medical condition (e.g. complex partial seizures).

Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Depersonalization disorder

Depersonalization disorder is characterized by an unpleasant state in which external objects or parts of the body are experienced as changed in their quality, and feel unreal or remote. Transient symptoms of depersonalization are quite common as a minor feature of other syndromes, and the symptoms of depersonalization disorder occur occasionally in association with other psychiatric disorders (see differential diagnosis below). However, primary depersonalization disorder is rare. It is uncertain exactly how rare it is because estimates of the prevalence vary so widely that no useful conclusion can be drawn (Reutens et al., 2010).

Although it is classified as a dissociative disorder in DSM-IV, it is not certain whether dissociation is indeed the causal mechanism of depersonalization disorder (see the section on aetiology below). In ICD-10 this uncertainty is recognized by giving the disorder its own place in the classification, separate from the dissociative disorders.

Clinical picture

The central features are a feeling of being unreal, and an unreal quality to perceptions. Emotions seem dulled and actions feel mechanical. Paradoxically, this lack of feeling is experienced as extremely unpleasant. Insight is retained into the subjective nature of the patient’s experiences. These symptoms may be intense, and accompanied by déjà vu and changes in the experience of the passage of time. Some patients also complain of sensory distortions affecting a single part of the body (usually the head, the nose, or a limb), which some individuals describe as feeling as if that body part is made of cotton wool.

Two-thirds of the patients are women. The onset is often in adolescence or early adulthood, with the condition starting before the age of 30 years in about 50% of cases. The symptoms usually begin suddenly, and once established they may persist for years, though with periods of partial or complete remission.

Differential diagnosis

Before diagnosing depersonalization disorder, any primary disorder must be excluded, especially temporal lobe epilepsy, schizophrenia, depressive disorder, obsessional disorder, conversion disorder, another dissociative disorder, generalized and phobic anxiety disorders, and panic disorder. Severe and persistent depersonalization is experienced by some people with schizoid personality disorder.

Most patients who present with depersonalization will be found to have one of these other disorders. The primary syndrome is rare.

Aetiology

The causes of primary depersonalization disorder are not known. Apart from the possible association with schizoid personality disorder, no definite constitutional factors have been identified. Sierra et al. (2002) reported that the stimulus response was faster than in controls, suggesting a heightened state of alertness. At the same time, autonomic responses to unpleasant stimuli were reduced, suggesting a selective inhibition of emotional processing. It is unclear why depersonalization is short-lived in most people, while in a small minority it persists as depersonalization disorder.

Prognosis

Secondary cases have the prognosis of the primary condition. The rare primary depersonalization disorder has not been followed systematically, but clinical experience indicates that cases which last for longer than a year have a poor long-term outcome.

Treatment

When depersonalization is secondary to another disorder, treatment should be directed to the primary condition. For primary depersonalization disorder, anxiolytic drugs may give short-term relief, but they should not be prescribed for long periods because of the risk of dependency. Supportive interviews can help the patient to function more normally despite the symptoms, and any stressors should be addressed. Claims that have been made about the value of lamotrigine (Sierra et al., 2003) have not been confirmed, nor have claims for the efficacy of cognitive–behavioural treatments or dynamic psychotherapy (Simeon et al., 2003). In this, as in other conditions that are difficult to treat, it is important to resist the temptation to give ineffective treatments in order to appear to be doing something for the patient. It is better to give adequate time for supportive care.

Other dissociative syndromes in ICD-10 (not specifically listed in DSM-IV)

Dissociative stupor

In dissociative stupor, patients show the characteristic features of stupor. They are motionless and mute, and they do not respond to stimulation, but they are aware of their surroundings. Dissociative stupor is rare. It is essential to exclude other possible conditions, namely schizophrenia, depressive disorder, mania, and organic brain diseases.

Ganser’s syndrome

Ganser’s syndrome is a very rare condition that has four features:

1. giving ‘approximate answers’ (see below) to questions designed to test intellectual functions

2. psychogenic physical symptoms

3. hallucinations

4. apparent clouding of consciousness.

The syndrome was first described among prisoners (Ganser, 1898), but is not confined to them. The term approximate answers refers to answers (to simple questions) that are plainly wrong but are clearly related to the correct answer in a way which suggests that the latter is known. For example, when asked to add two plus two, a patient might answer five, while if asked to add three plus three he might answer seven. The obvious advantage to be gained from the condition, coupled with the approximate answers, suggests malingering. However, the condition is often maintained so consistently that unconscious mental mechanisms have been thought to play a part. For some naive individuals this may represent their only way of communicating effectively their distress and anxiety. It is important to exclude an organic brain disease or schizophrenia; the former should be considered particularly carefully when muddled thinking and visual hallucinations are part of the clinical picture.

For a review, see Dwyer and Reid (2004).

Trance and possession disorder

Trance and possession disorder is included in dissociative (conversion) disorder in ICD-10. DSM-IV lists it in Appendix B (Criteria Sets and Axes Provided for Further Study) as dissociative trance disorder.

Trance and possession states are characterized by a temporary loss of the sense of personal identity and of full awareness of the surroundings. Such states are induced temporarily in willing participants in religious or other ceremonies, and also recreationally in ‘raves’, often aided by drug use. When they arise in this way, the states are not recorded as disorders. According to DSM-IV they become disorders when there is:

an involuntary state of trance not accepted by the person’s culture as a normal part of a collective cultural or religious practice and that causes clinically significant distress or functional impairment.

Some cases resemble multiple personality disorder, in that the person behaves as if they have been taken over by another personality for a brief period. When the condition is induced by religious ritual, the person may feel as if they have been taken over by a deity or spirit. The focus of attention is narrowed to a few aspects of the immediate environment—for example, to the priest conducting a religious ceremony. The affected person may repeatedly perform the same movements, or adopt postures, or repeat utterances.

Cultural syndromes

Certain patterns of unusual behaviour, restricted to certain cultures, have been thought to reflect psychological mechanisms of dissociation. Some of these behaviours can be classified as ‘cultural-bound syndromes.’ This term has been criticized because of its ‘ethnocentric’ implications—that all mental disorders are best, or only, understood from a European perspective. It is applied to syndromes in non-Western cultures but not to syndromes which are found particularly in Western cultures (e.g. eating disorders, chronic fatigue syndrome). Many of the early descriptions were associated with explicit or implicit racist ideas, and these terms should be used with circumspection.

Examples of cultural syndromes include the following:

• Latah, which is found among women in Malaya, is characterized by echolalia, echopraxia, and other kinds of abnormally compliant behaviour. The condition usually follows a frightening experience.

• Amok has been described among men in Indonesia and Malaya (Van Loon, 1927). It begins with a period of brooding, which is followed by violent behaviour and sometimes dangerous use of weapons. Amnesia is usually reported afterwards. It is unlikely that all patients with this pattern of behaviour are suffering from a dissociative disorder; some may be suffering from mania, schizophrenia, or a post-epileptic state.

• Arctic hysteria (piblokto) is seen among the Inuit, more often in women. The affected person tears off her clothing, screams and cries, runs about in distress, and may endanger her life by exposure to cold. Sometimes the behaviour is violent. The relationship of this syndrome to dissociative disorder is not firmly established, and there may be more than one cause.

Recovered memories and false-memory syndrome

These conditions are described on p. 174.

Factitious dissociative identity disorder

There is wide agreement, even among those who believe that dissociative identity disorder is common, that both factitious and malingered presentations are also common (Coons, 1998).

Psychiatric services in medical settings

Psychiatric services for general hospitals are named and organized in several ways.

Consultation–liaison psychiatry (sometimes known as C-L psychiatry or liaison psychiatry) is the traditional term. In consultation work, the psychiatrist is available to give opinions on patients referred by physicians and surgeons. In liaison work the psychiatrist is a member of a medical or surgical team, and offers advice about any patient to whose care he feels able to contribute. The liaison psychiatrist also assists other staff in dealing with day-to-day psychological problems encountered in their work, including the problems of patients whom staff have discussed but the psychiatrist has not interviewed.

Psychological medicine is a general term for the use of consultation and liaison methods to enable medical and nursing staff to provide basic psychological and psychiatric care (see Mayou et al., 2004).

Behavioural medicine is the term used to refer to similar arrangements provided by clinical psychologists rather than psychiatrists.

Psychosomatic medicine is a term that was widely used in the past in the USA and elsewhere, and is still current in Germany. It has been revived in the USA as the name for consultation–liaison psychiatry as a recognized sub-specialty of psychiatry (Gitlin et al., 2004).

The make-up of services

Consultation and liaison units vary in their size and organization. Some are staffed entirely by psychiatrists, and others by a multidisciplinary team of psychiatrists, nurses, social workers, and clinical psychologists. A few liaison services have inpatient beds for patients who are both medically and psychiatrically ill. In a few North American hospitals with large consultation–liaison services, up to 5% of all admissions are referred to psychiatrists. In the UK and many other countries, a smaller proportion of inpatients are referred, most of which are emergencies, especially those involving deliberate self-harm (see Chapter 16). Most of the literature on consultation–liaison psychiatry has focused on inpatients, but most of the patients who are actually referred are from outpatient clinics and emergency departments.

Consultation–liaison psychiatry is increasingly concerned with the provision of psychiatric and psychological assessment, and the collaborative management of patients with either medically unexplained symptoms or psychiatric disorders comorbid with chronic medical illness. A major challenge is to find ways of extending these overstretched services to similar patients who are being treated in primary care.

For further information about consultation–liaison psychiatry and psychosomatic medicine, see Leentjens et al. (2011).

Psychiatric consultation in a medical setting

The consultation has two parts—the assessment of the patient, and communication with the patient and with the doctor who is making the referral. Assessment is similar to that of any other patient who is referred for a psychiatric opinion, except that in addition it is necessary to take into account their medical condition and treatment, and their willingness to see a psychiatrist.

First steps

Having received the request for a consultation, the psychiatrist should make sure that the referring doctor has adequately discussed the psychiatric referral with the patient, and that the latter has agreed to see the psychiatrist. Before interviewing the patient, the psychiatrist should read the relevant medical notes and ask the nursing staff about the patient’s mental state and behaviour. The psychiatrist should find out what treatment the patient is receiving, and if necessary consult a work of reference about the side-effects of any drugs.

The assessment interview

At the start of the interview the psychiatrist should make clear to the patient the purpose of the consultation. It may be necessary to discuss the patient’s concerns about seeing a psychiatrist (e.g. to reassure them that it does not imply that they are mad or that the referring doctor disbelieves them), and to explain how the interview may contribute to the treatment plan (by adding another kind of expertise to their medical care).

Next, an appropriately detailed history should be obtained and the mental state examined. Usually the medical status is already recorded in the case notes. Occasionally it will be necessary to perform some physical examination (e.g. of the nervous system).

After the interview, it may be necessary to ask further questions of the ward staff or a social worker, to interview relatives, or to telephone the family doctor and enquire about the patient’s social background and any previous psychiatric disorder.

Clinical notes

The psychiatrist should keep separate full notes of the examination of the patient and of interviews with informants. The entry in the medical notes should be different from these psychiatric notes. It should be brief and free from psychiatric jargon, and should contain only information essential for those who are caring for the patient. As far as possible it should omit confidential information, focus on practical issues, and answer the questions raised by the referring doctor.

Writing the response to the referral

It is often appropriate to discuss the proposed plan of management with the consultant, ward doctor, or nurse in charge before writing a final opinion. In this way the psychiatrist can make sure that recommendations are feasible and acceptable, and that answers have been given to the questions asked about the patient.

The entry in the medical notes should be along the lines of a letter to a general practitioner (see p. 63). It is important to make clear the nature of any immediate treatment that is recommended, and who is to provide it. If the assessment is provisional until other informants have been interviewed, the psychiatrist should state when the final opinion will be given. The notes should be signed legibly, and should inform the ward staff where the psychiatrist or a deputy can be found if further help is required.

Management

Treatment is similar to that of a similar psychiatric disorder in a medically well patient. However, when psychiatric drugs are prescribed, special attention should be paid to the possible effects of the patient’s medical condition on their metabolism and excretion, and to any possible interactions with other drugs that the patient is taking. The plan should be based on a realistic assessment of the amount of supervision that is available on a medical or surgical ward (e.g. in relation to a depressed patient with suicidal ideas). With support from a psychiatrist the nursing staff can manage most brief psychiatric disorders that arise in a general hospital, although some support may be needed from a psychiatric nurse (who may be a member of the consultation–liaison team).

Continuing care

The psychiatrist may need to review the patient’s progress while they are in hospital. After discharge it is important to attempt to ensure continuity of care by speaking or writing to the patient’s general practitioner. According to the needs of the case, care may be continued by the general practitioner, or the liaison psychiatrist may continue to see the patient, or care may be transferred to the community psychiatric team.

Some common emergency problems

General approach

The successful management of any psychiatric emergency depends importantly on the initial clinical interview. The aims are those of any assessment interview, namely to establish a good relationship with the patient, to elicit information from the patient and other informants, and to observe the patient’s behaviour and mental state. A relaxed, sympathetic, and firm approach helps to calm the situation enough for the doctor to reach an understanding of the patient’s concerns and suggest a plan that the patient will agree to. In an emergency, it may not be possible to conduct a full assessment interview, but the assessment should be as systematic and complete as the circumstances permit (see also p. 53).

The anxious patient

Panic attacks. The somatic symptoms of a panic attack are frequent reasons for an emergency presentation. Common features include non-cardiac chest pain, tingling in the extremities, and the effects of hyperventilation (see p. 195). Most patients can be talked through an episode of panic, and hyperventilation responds to rebreathing into a paper bag. Occasionally a small dose of a benzodiazepine is needed to control the anxiety. Follow-up with treatment for panic disorder (see p. 197) may be required.

Severe generalized anxiety may complicate any medical presentation. Attendance at an emergency department can be a frightening experience, and the consequent anxiety may be made worse by the response of unaware staff. It is usually possible to reduce the anxiety by explaining what is happening in a sympathetic manner. Occasionally a small dose of a benzodiazepine may be required to control the anxiety.

The angry patient

It can be very upsetting to clinicians and other carers when the person they are trying to help responds with anger. If this happens, it is essential to keep calm and avoid doing or saying anything that may increase the patient’s anger, and to be careful about physical safety (see below). The clinician should try to find out and understand why the patient is angry. Sometimes it is helpful to comment on the anger and to ask directly why the person is so upset. It is always unwise either to show anger in return or to be unduly submissive. It may be necessary to apologize for the problem that has caused the anger—for example, if the patient has been kept waiting for a long time.

The aggressive or violent patient

If the patient is actually or potentially violent, it is essential to arrange for adequate but unobtrusive help to be available. Physical contact (including physical examination) should not be attempted unless the purpose has been clearly understood by and agreed with the patient. If restraint cannot be avoided, it should be accomplished quickly by an adequate number of people using the minimum of force. Staff should not attempt single-handed restraint. Extreme caution is, of course, required if the patient could be in possession of an offensive weapon. Aggressive and violent patients are also discussed on p. 51.

Emergency drug treatment for disturbed or violent patients

Diazepam (5–10 mg) may be useful for a patient who is frightened. Intramuscular lorazepam and intramuscular haloperidol (2–5 mg, repeated) can be used for those who are psychotic and have been exposed to antipsychotics. Haloperidol or olanzapine (oral or intramuscular) is recommended in delirium unless this is secondary to alcohol withdrawal. When the patient has become calm, medication may be continued in smaller doses, usually three to four times a day and preferably by mouth, using syrup if the patient will not swallow tablets. The dosage depends on the patient’s weight and on the initial response to the drug. Careful observations by nurses of the physical state and behaviour are necessary during this treatment. Extrapyramidal side-effects may require treatment with an antiparkinsonian drug (see p. 525).

Box 15.8 Medico-legal and ethical issues: patients who refuse to accept advice about emergency treatment

• In life-threatening emergencies where it is not possible to obtain the patient’s consent (i.e. consciousness is impaired, or there is evidence of psychiatric disorder which cannot be immediately assessed), opinions should be obtained from medical and nursing colleagues, and if possible from the patient’s relatives. Detailed records should be kept of the reasons for the decision. It is essential for all doctors to be familiar with the law about these matters in the country in which they are practising.

• If a patient has a mental disorder that impairs the ability to give informed consent, it may be appropriate to use legal powers of compulsory assessment and treatment of the mental disorder. In the UK, the powers for compulsory treatment of a mental disorder do not give the doctor a right to treat concurrent physical illness against the patient’s wishes. However, after successful treatment of the psychiatric disorder, the patient may decide to give informed consent for the treatment of the physical illness.

Problems in consent to treatment

General principles relating to consent to treatment are discussed in Chapter 4. Psychiatrists are sometimes asked to give advice about patients who are refusing to accept medical or surgical treatment. There are several reasons why patients may be unwilling to accept treatment that is recommended to them. They may not have understood the information that they have been given, they may be frightened or angry, or, occasionally, they may have a mental illness that interferes with their ability to make an informed decision.

It has to be accepted that a conscious, mentally competent adult has the right to refuse treatment even after a full and rational discussion of the reasons for carrying it out. If the patient’s condition is such that they cannot give consent, then in the UK and many other countries the doctor in charge of the patient has the right to give immediate treatment in life-threatening emergencies. The medico-legal issues are summarized in Box 15.8.

For a review of the management of psychiatric syndromes in intensive-care units, see Boland et al. (2000). For a review of ethical issues in the care of the medically ill, see Strain et al. (2000).

Psychiatric aspects of medical procedures and conditions

Genetic counselling

Genetic counselling about the reproductive risks of hereditary disease is mainly given to couples who are contemplating marriage, or planning or expecting a child. Psychiatrists used to be involved in this, but it is now the responsibility of medical geneticists, not least because of rapid developments in the range and methods of testing available. Counselling includes:

• providing information about risks

• helping individuals to cope with concerns about the diagnosis

• enabling patients to make informed decisions about family planning.

Occasionally, medical geneticists may request the collaboration or advice of psychiatrists, particularly when potential parents appear to be significantly distressed by the advice and unable to concentrate on making decisions.

Psychiatric aspects of surgical treatment

Pre-operative problems

Patients who are about to undergo surgery are often anxious, and those who are most anxious before operation are likely to be anxious afterwards. Most studies of psychological preparation for surgery have shown that it can reduce post-operative distress, especially when the preparation includes measures to improve coping.

Psychiatrists may be asked to assess patients before surgery. Common reasons for such a request include the following:

• clarification of the role of emotional factors in the patient’s physical complaints

• uncertainty about the patient’s cognitive state and their capacity to provide informed consent

• help with the management of current psychiatric problems

• help with predicting the patient’s response to surgery and their capacity to cooperate with post-operative treatment and rehabilitation.

Psychiatric problems in the post-operative period

Delirium

Delirium is common after major surgery, especially in the elderly (Brown and Boyle, 2002). Whether delirium develops depends on the type of surgery, the type of anaesthetic, the presence of post-operative physical complications, and the type of medication. Delirium is associated with increased mortality and longer duration of hospitalization.

Pain

Psychiatrists are sometimes asked to advise on the management of patients with unusually severe post-operative pain. Patients who are given greater control over the timing of analgesia usually experience less pain and make less use of analgesia. Some are helped by anxiety management, and others by support with resolving anger arising, for example, from disagreements with the staff who are caring for them.

Long-term psychological problems after surgery

Adjustment problems are particularly common after mastectomy and laryngectomy, and after surgery that has not led to the expected benefit. Psychiatrists can sometimes contribute to the management of such problems, especially when the surgery is part of the treatment of a relapsing, chronic, or progressive disorder. The psychiatrist may help to discover psychosocial factors that are impeding adjustment, and help the patient to resolve or come to terms with the problems. Some patients require antidepressant medication.

For reviews, see Hales et al. (2009) and Stoddard et al. (2000).

Plastic surgery

People with physical deformities often experience embarrassment and distress, and this may markedly restrict their lives as children and as adults. When such patients are psychiatrically healthy, plastic surgery usually gives good results. Even when there is no major objective defect to match the concerns about appearance, cosmetic surgery to the nose, face, and breasts is usually successful. Nevertheless, psychological assessment can contribute to assessment before plastic surgery, as the outcome is likely to be poor in patients who have delusions about their appearance, dysmorphobia, or greatly unrealistic expectations, or who have been dissatisfied with previous surgery. For a review, see Van Soest et al. (2009).

Limb amputation

Limb amputation has different psychological consequences for young and elderly people. Young adult amputees, such as those who lose a leg as a result of a road accident or during military action, characteristically show denial at first, and may later experience depression and phantom limb pains which resolve slowly. Children and adolescents seem to have a similar outcome. Older people usually undergo amputation after prolonged problems associated with vascular disease. Such patients do not commonly report severe distress immediately after the operation, but they often develop phantom limb pain. Some have difficulty with the prosthesis and show a degree of functional incapacity that is disproportionate to their physical state.

Organ transplantation

These operations have considerable associated psychiatric consequences related to the nature of the surgery, and the need for continuing intensive medical care.

Selection for transplantation. The selection process can be stressful, as can the wait for a suitable organ, although the wait for kidney transplants tends to be less stressful because there is the alternative of continuing dialysis during the waiting period. There are few psychological contraindications for these operations, and most relate to inability to cope with the demands of the necessary long-term post-operative care. After operation, transplantation is associated with the same psychiatric and emotional problems that occur after other major surgery, especially anxiety, delirium, and depression. There are also some problems specific to a particular type of transplant. For example, liver transplantation has the highest rate of pre- and post-operation neuropsychiatric complications.

These problems are sufficiently frequent and serious to justify psychiatric liaison with transplant units in order to support staff and train them to recognize and respond appropriately to patients who have such problems (Heinrich and Marcangelo, 2009).

Diabetes

Diabetes mellitus

Diabetes is a chronic condition that requires prolonged medical supervision and informed self-care, and many physicians emphasize the psychological aspect of treatment.

Psychological factors and diabetic control

Psychological factors are important in established diabetes because they influence its control, and it is now generally accepted that good control of blood glucose concentration is the most important single factor for preventing long-term complications. Psychological factors can impair control in two ways. First, stressful experiences can lead to endocrine changes. Secondly, many diabetics do not adhere well to their treatment regime, especially at times of stress, and this is an important cause of ‘brittle’ diabetes.

Problems of being diabetic

Psychological and social problems may be caused by restrictions of diet and activity, the need for self-care, and the possibility of serious physical complications such as vascular disease and impaired vision. Although most diabetic people overcome or adapt to such problems, an important minority have difficulties. Adherence to regimes for testing, diet, and insulin is often unsatisfactory, so that glycaemic control is less than optimal. Problems of this kind are particularly likely to occur in adolescence.

Other problems

Associated eating disorder. Control of diabetes is more difficult when the diabetic person has an eating disorder. Some women with diabetes and eating disorders also misuse insulin in order to lose weight.

Associated medical complications. Psychosocial problems are more than usually common in diabetics who have severe medical complications, such as loss of sight, renal failure, and vascular disease. Diabetic neuropathy is often very painful and can restrict activities.

Sexual problems are common among diabetics. Two kinds of impotence occur in diabetic men. The first is psychogenic impotence of the kind found in other chronic debilitating diseases. The second kind is more common in diabetes, and may pre-date other features of the disease. It is thought to be associated with pelvic autonomic neuropathy and vascularity, while endocrine factors may play a part.

Pregnancy is a difficult time for diabetic women, with problems in the control of diabetes and increased risks of miscarriage and fetal malformations.

Organic psychiatric syndromes in diabetic patients

Delirium. The first evidence of developing diabetic coma is sometimes an episode of disturbed behaviour, starting either abruptly or insidiously. The cause of the behaviour becomes clearer as other prodromal symptoms develop, including thirst, headaches, abdominal pain, nausea, and vomiting. The pulse is rapid and blood pressure is low. Dehydration is marked and acetone may be smelt on the breath.

Chronic cognitive impairment. Mild dementia is not uncommon among those with chronic diabetes. It may be caused by recurrent attacks of hypoglycaemia or by cerebral arteriosclerosis. More severe dementia may develop in patients with associated cerebrovascular disease.

Psychiatric aspects of management

Diabetes has been the object of considerable psychiatric research involving a range of psychological treatments, particularly in adolescent and brittle diabetics. Possible measures include treatment for depressive disorder, blood glucose awareness training to improve the ability to recognize and act on fluctuations in blood glucose concentration, weight management programmes, cognitive–behavioural approaches to improve self-care, help with psychosocial problems, and treatment of sexual dysfunction. Tricyclic antidepressants may be helpful in relieving the pain of neuropathy. For a review of psychological care of patients with insulin-dependent diabetes, see Plack et al. (2010).

Other endocrine disorders

Many endocrine disorders, and most conspicuously thyroid dysfunction, have been associated with psychiatric complications. Box 15.9 summarizes some of the more common associations, together with aspects of steroid therapy.

For a review of the psychiatric aspects of endocrine disorder, see Harrison and Kopelman (2009).

Box 15.9 Psychiatric aspects of other endocrine disorders and steroid therapy

Hyperthyroidism (thyrotoxicosis). May present with psychiatric symptoms such as anxiety, irritability, emotional lability, and difficulty in concentrating. These, together with hyperactivity, fatigue, and tremor, may make differential diagnosis from anxiety disorder difficult. Treatment of thyroid dysfunction usually results in improvement of the psychiatric symptoms.

Hypothyroidism (myxoedema). Cognitive impairment and other psychiatric disorders are common. Mood disorder may take a rapid-cycling form. Replacement therapy may reverse the mood symptoms, but neuropsychiatric problems may persist. For a review, see Dugbartey (1998).

Hyper-adrenalism (Cushing’s syndrome). Depressive symptoms are common. Their severity is not closely related to plasma cortisol levels, and personality and stressful circumstances may play a part. Psychological symptoms usually improve quickly when the medical condition is controlled. Paranoid symptoms also occur, especially in those with the most severe illness. See W. F. Kelly (1996) and Sonino and Fava (1998).

Steroid therapy. Affective symptoms, especially euphoria or mild mania, are frequent. Paranoid symptoms are less common. The severity of the mental disorder is not closely associated with dosage. Symptoms usually improve when the dose is reduced but, when severe, lithium prophylaxis should be considered for patients who need to continue steroid treatment after a mood disorder has been controlled. Withdrawal of corticosteroids may cause lethargy, weakness, and joint pain.

Anabolic steroids. Anabolic–androgenic steroids are widely used by athletes. Mood disturbances and increased aggression have been reported. See Wroblewska (1997), W. F. Kelly (1996), and Sonino and Fava (1998).

Other metabolic and autoimmune disorders

Psychiatric aspects of the porphyrias, sarcoidosis, systemic lupus erythematosus, and myasthenia gravis are considered in Section 5.3.4 of the New Oxford Textbook of Psychiatry (Gelder et al., 2009). Anti-NMDA-receptor encephalitis has recently been identified (Dalmau et al., 2008), which can present to psychiatrists as well as neurologists. (See also Chapter 13 for a discussion of neuropsychiatric disorders.)

Cardiac disorders

For many years it has been suggested that emotional disorder predisposes to ischaemic heart disease, and Dunbar (1954) described a ‘coronary personality.’ Recent research has focused on several possible risk factors, including chronic emotional disturbance, social and economic disadvantage, overwork and other chronic stress, and the so-called ‘type A behaviour pattern’ or ‘type A personality.’ The latter consists of hostility, excessive competitive drive, ambition, a chronic sense of urgency, and a preoccupation with deadlines (Friedman and Rosenman, 1959). Although type A behaviour has been widely accepted as an independent risk factor for ischaemic heart disease, recent evidence has cast doubt on this conclusion.

Angina

Angina is often precipitated by emotions such as anxiety, anger, and excitement. It is a frightening symptom, and some patients become overcautious despite reassurance and encouragement to resume normal activities. Angina is sometimes accompanied by atypical chest pain and breathlessness caused by anxiety or hyperventilation, and it is important to identify this rather than increasing medical anti-angina therapy.

Myocardial infarction

Patients often respond to the early symptoms of myocar-dial infarction with denial, and consequently delay seeking treatment. During the first few days in hospital, acute organic mental disorders and anxiety symptoms are common.

Recent research has focused on the replicated finding that depression, anxiety, and social isolation are important risk factors both for a lower quality of life (Dickens, 2006) and for death after myocardial infarction (Carney et al., 2009).

Some survivors of cardiac arrest suffer cognitive impairment. When such impairment is mild, it may be manifested later as apparent personality change or as behavioural symptoms which may be wrongly attributed to an emotional reaction to the illness.

When patients return home from hospital, they commonly report non-specific symptoms such as fatigue, insomnia, and poor concentration, as well as excessive concern about somatic symptoms and an unnecessarily cautious attitude to exertion. Most patients overcome these problems and return to a fully active life. A few continue to experience emotional distress and social disability out of proportion to their physical state, often accompanied by atypical somatic symptoms. Such problems are more common in patients with long-standing psychiatric or social problems, overprotective families, and myocardial infarction with a complicated course.

The finding that depression and social isolation are associated with increased mortality after myocardial infarction has led to research designed to evaluate interventions for treating depression and reducing social isolation. In the large trials that have been completed so far, nursing support to combat social isolation was ineffective. Cognitive–behaviour therapy is effective in treating depression, and may reduce recurrences (Gulliksson et al., 2001). However, antidepressant treatment has not been demonstrated to improve outcomes after myocardial infarction (Van Melle et al., 2007).

Non-cardiac chest pain

During the American Civil War, Da Costa (1871) described a condition which he called ‘irritable heart.’ This syndrome consisted of a conviction that the heart was diseased, together with palpitations, breathlessness, fatigue, and infra-mammary pain. This combination has also been referred to as ‘disorderly action of the heart’, ‘effort syndrome’, and ‘neurocirculatory asthenia.’ The symptoms were originally thought to indicate a functional disorder of the heart.

Non-cardiac chest pain, in the absence of heart disease and often associated with complaints of breathlessness and palpitations, is very common among patients in primary care and in cardiac outpatient clinics. Most patients with the symptoms are reassured by a thorough assessment, but a significant minority continue to complain of physical and psychological symptoms and to limit their everyday activities. Follow-up studies of patients with chest pain and normal coronary angiograms have consistently found subsequent mortality and cardiac morbidity to be little higher than in those without cardiac disease, but persistent disability is common.

Many causes have been suggested for atypical cardiac symptoms, including pain originating in the chest wall, oesophageal reflux and spasm, microvascular angina, mitral valve prolapse, and psychiatric disorder. In most patients, chest pain appears to be due to minor non-cardiac physical causes or to hyperventilation, which are misconstrued as heart disease and associated with anxiety. The aetiology is as for other medically unexplained symptoms (see p. 386). The most common psychiatric concomitant is panic disorder; less commonly associated with non-cardiac chest pain are depressive disorder and hypochondriasis.

Management should follow the general principles described on p. 388, with a particular emphasis on the treatment of hyperventilation, graded increase in activity, and discussion of beliefs about the cause of the pain. Cognitive–behaviour therapy may be effective in the management of anxiety with hyperventilation. Depressive disorder should be treated with antidepressant medication. For a review, see Fass and Dickman (2006).

Sensory disorders

Deafness

Deafness may develop before speech is learned (prelingual deafness) or afterwards. Profound early deafness interferes with speech and language development, and with emotional development. Prelingually deaf adults often keep together in their own social groups and communicate by sign language. When they have problems, it appears that these are more often behaviour problems and social maladjustment than emotional disorder. These problems are managed best by those with special knowledge of the effects of deafness.

Deafness of later onset has less severe effects than those just described. However, the acute onset of profound deafness can be extremely distressing, while milder restriction of hearing may cause depression and considerable social disability.

Kraepelin was the first to suggest that deafness is an important factor in the development of persecutory delusions. Subsequent evidence supports an association between deafness and paranoid disorders in the elderly (see p. 299). For a review, see Hindley and Kitson (1999).

Tinnitus

Tinnitus is very common, but few patients seek treatment, and most are able to live a normal life. Persistent tinnitus may be associated with low mood. Some patients are helped by devices that mask tinnitus with a more acceptable sound. Antidepressant medication may improve mood and reduce the intensity of the tinnitus (Sullivan et al., 1993). Cognitive and behavioural methods may enable people to accept their tinnitus and to minimize their social handicaps, and may perhaps protect against the increased risk of suicide in this disorder.

Blindness

Although it imposes many difficulties, blindness in early life need not lead to abnormal psychological development in childhood or to unsuccessful later development. In previously sighted people, the later onset of blindness often causes considerable distress. Initial denial and subsequent depression are common, as are prolonged difficulties in adjustment. For a review, see Berman and Brodaty (2006).

Infections

Acute infections. Psychological factors may affect the course of recovery from an acute infection (Hotopf et al., 1996). In a classic early study, psychological tests were completed by 600 people who subsequently developed Asian influenza. Delayed recovery from the influenza was no more common among people whose initial illness had been severe, but it was more frequent among those who had obtained more abnormal scores on the psychological tests before the illness (Imboden et al., 1961). More recent findings of research on viral illness in general practice and infectious mononucleosis have reported similar conclusions (White et al., 1998). The role of infection as a cause of chronic fatigue syndrome is discussed on p. 389.

Viral encephalitis is often accompanied by psychiatric symptoms. In addition, some infectious diseases—for example, hepatitis A, influenza, and brucellosis—are frequently followed by periods of depression and fatigue.

HIV infection

HIV infection affects the brain at an early stage, and the disease has a chronic progressive course associated with a wide range of psychiatric consequences. Even so, many patients with AIDS manage to lead relatively normal lives for substantial periods. The nature of the physical symptoms, their progressive course, and the reactions of other people all explain why emotional distress is common in people with HIV infection. A further reason is that some of those at high risk for HIV (e.g. drug abusers) may have other psychological problems. The effects on the patient’s family may be considerable, especially if the partner and/or one or more of the children are infected. Women may be concerned about the effects of the infection on childbearing. Psychiatrists can contribute to the care of AIDS patients by providing counselling and specialist treatment for neuropsychiatric and other psychiatric complications.

Reactions to testing. Although HIV-antibody testing is worrying for most of those who undergo it, the distress is usually short-lived whatever the outcome of the test. People who have persistent and unjustified worries about having AIDS require psychiatric help of the kind that is appropriate for other illness fears (see p. 187).

Psychiatric problems, including adjustment disorder, depressive disorder, and anxiety disorder, are frequent at the time of diagnosis, although they may occur at any stage of the disease. People with previous psychological problems, long-standing social difficulties, or lack of social support are especially vulnerable.

Suicide and deliberate self-harm may occur in people who are concerned about the possibility of HIV infection, as well as in people with proven disease. Among the latter, the risk is greater in those with advanced symptoms. However, it is not certain how much greater the risk of suicide and deliberate self-harm is in AIDS patients compared with the general population.

Neuropsychiatric disorders are common, both secondary to the complications of immune suppression and as direct effects of HIV on the brain. Minor cognitive disorders are frequent. HIV-associated dementia (AIDS–dementia complex), HIV encephalopathy, and subacute encephalitis occur late in the illness in around one-third of patients. There is usually an insidious onset with progression to profound dementia. HIV infection can also result in neurological symptoms and dementia in those who do not have AIDS. Delirium may occur when there is an opportunistic infection or cerebral malignancy (Dilley and Fleminger, 2009).

The social consequences are considerable because of public fears about the condition, and the stigma attached to it. Cultural differences in acceptance or rejection, and in the availability of family and other support, are major determinants of quality of life.

Problems in relation to illicit drug use are considered on p. 466. The disorganized lives of some drug users and their personal and social problems can make the treatment of HIV difficult.

Ethical problems are related to confidentiality. They include the importance of maintaining confidentiality, disclosure to third parties who are at risk of infection, disclosure to insurers and to employers, and protection of the public from the risk of transmission from HIV-infected healthcare workers.

Cancer

The psychological consequences of cancer are similar to those of any other serious physical illness, and include the following:

• Delay in seeking medical help. This may be due to either fear or denial.

• Response to the diagnosis. This may consist of anxiety, shock, anger, disbelief, or depression. Sometimes the response is severe enough to meet the criteria for a psychiatric disorder, usually an adjustment disorder or sometimes a depressive disorder. The risk of suicide is increased, particularly in the year after diagnosis (Hem, 2004).

• Major depression. This occurs throughout the course of cancer, affecting 10–20% of patients, and appears to be more frequent in those suffering pain. The rate is similar to that among other physically ill patients (Holland, 2010).

• The progression and recurrence of cancer are often associated with increased psychiatric disturbance, which may result from a worsening of physical symptoms such as pain and nausea, from fear of dying, or from the development of an organic psychiatric syndrome.

• Delirium and dementia may arise from brain metastases, which originate most often from carcinoma of the lung, but also from tumours of the breast and alimentary tract, and from melanomas. Occasionally, brain metastases cause psychiatric symptoms before the primary lesion is discovered (see also Chapter 13).

• Neuropsychiatric problems (paraneoplastic syndromes) are sometimes induced by certain kinds of cancer in the absence of metastases, notably by carcinoma of the lung, ovary, breast, and stomach, and Hodgkin’s lymphoma. The aetiology is thought to be an autoimmune response to the tumour.(see also Chapter 13).

Treatment for cancer may cause psychological disorder. Emotional distress is particularly common after mastectomy and other mutilating surgery. Radiotherapy causes nausea, fatigue, and emotional distress. Chemotherapy often causes malaise and nausea, and anxiety about chemotherapy may cause anticipatory nausea before the treatment. The latter may be helped by behavioural treatments in addition to anti-emetic medication.

Family and other close relatives of cancer patients may experience psychological problems, which may persist even if the cancer is cured. Nevertheless, many patients and relatives make a good adjustment to cancer. The extent of their adjustment depends partly on the information that they receive.

Treatment for psychological consequences

In the past doctors were reluctant to tell patients that the diagnosis was cancer, but most patients prefer to know the diagnosis and how it will affect their life. However, the information must be communicated well, otherwise there may be problems in achieving a psychological adjustment. Depression and anxiety disorders are often missed in these patients, and systematic screening has been recommended (Miovic and Block, 2007; Fann et al., 2008).

Cognitive–behavioural approaches can help these patients to adjust (Sheard and Maguire, 1999; Akechi et al., 2008). Patients who are most likely to need such help include those with a history of previous psychiatric disorder or poor adjustment to other problems, and those who lack a supportive family. Earlier findings that suggested specific reaction types (e.g. ‘fighting spirit’) or the usefulness of targeted psychotherapy have not been confirmed by later work.

Childhood cancer

Childhood cancer presents special problems. Communication of the diagnosis is particularly difficult, but it is generally better to explain the diagnosis in terms appropriate to the child’s stage of development. The child often reacts to the illness and its treatment with behaviour problems. Many parents react at first with shock and denial, and may take months to accept the full implications of the diagnosis. Some mothers develop an anxiety or depressive disorder, and other family members may be affected. During the early stages of the illness, parents are usually helped by advice about practical matters, and later by discussion of their feelings, which often include guilt. Adult survivors of cancer in childhood or adolescence appear to be at risk of social difficulties.

For a review of psychiatric aspects of cancer, see Love-stone (2009).

Accidents

Psychiatric associations

Psychiatric disorder predisposing to accidents is often due to cognitive impairment occurring, for example, in alcohol or drug intoxication, delirium, or dementia, and less so in depression and some personality disorders.

Psychiatric disorder caused by accidents includes adjustment disorder, anxiety and depressive disorders, and post-traumatic stress disorder. Avoidance of situations associated with the accident is common, and may be severe enough to meet the diagnostic criteria for phobic anxiety disorder. Head injury may cause specific cognitive disorders (see p. 344).

Associations with particular kinds of accident

Criminal assault can have especially severe and persistent consequences for victims (Kilpatrick and Acierno, 2003). Victims’ problems are discussed further on.

Road traffic accidents are the leading cause of death in people under 40 years of age, and a major cause of physical morbidity. Psychiatric factors that contribute to road accidents include the misuse of alcohol and drugs, psychiatric illness, suicidal and risk-taking behaviour, and the side-effects of some prescribed psychotropic drugs. Psychiatric consequences of road accidents include acute stress disorder, anxiety and depressive disorders, post-traumatic stress disorder, phobias of travel, and disorders caused by brain injury. Some of these conditions are transient, but others persist and may cause considerable disability. Most of those affected do not appear to have been psychologically vulnerable before the accident (Hickling and Blanchard, 1999).

Occupational injury. The psychiatric consequences of occupational injury resemble those of other accidents. It is sometimes alleged that hopes of compensation or other benefits help to maintain the symptoms and disability (see the section on compensation neurosis below).

Spinal cord injury. Around 25% of patients who are admitted to a spinal injury unit suffer from psychiatric problems that require treatment. Depression is common in the period immediately after a spinal cord injury, but usually improves with time. Nevertheless, suicide appears to be more common among these patients than in the general population.

Burns. In children, burns are associated with overactivity, learning disability, child abuse, and child neglect. In adults, burns are associated with alcohol and drug misuse, deliberate self-harm, and dementia. Severe burns and their protracted treatment may cause severe psychological problems. Hamburg et al. (1953) have described three stages.

• Stage 1 lasts days or weeks. Denial is common. The most frequent psychiatric disorders are organic syndromes. At this stage the relatives often need considerable help.

• Stage 2 is prolonged and painful. Denial recedes and emotional disorders are more common. The patient needs to be helped to withstand pain, to express their feelings, and gradually to accept disfigurement.

• Stage 3. The patient leaves hospital and has to make further adjustments to deformity or physical disability and the reaction of other people to their appearance.

Post-traumatic stress disorder is common among people with severe burns, and persistent anxiety and depression occur in more than one-third of cases (Palmu et al., 2011). The outcome is worse for patients with burns that affect the face. Such individuals are likely to withdraw from social activities. These patients need considerable support from the staff of the burns unit, but only a minority also require referral to a psychiatrist.

‘Compensation neurosis’

The term compensation neurosis (or accident neurosis) refers to psychologically determined physical or mental symptoms that occur when there is an unsettled claim for compensation. It was believed that such psychological factors were important in claims for persistent physical disability after occupational injuries and road accidents. Compensation claims were thought to prolong symptoms, and it was believed that settlement was followed by recovery. More recent evidence has failed to substantiate this extreme view (Margoshes and Webster, 2000).

In fact many accident victims do not claim compensation, and few become involved in prolonged litigation. However, it does appear that time off work and disability are affected by the type of accident, social factors, and the prospect of compensation, social security, or other benefits.

For a review of the psychiatric aspects of accidents, burns, and other trauma, see Malt (2009).

Psychiatric aspects of obstetrics and gynaecology

Pregnancy

Psychiatric disorder is more common in the first and third trimesters of pregnancy than in the second trimester. In the first trimester, unwanted pregnancies are associated with anxiety and depression. In the third trimester there may be fears about the impending delivery or doubts about the normality of the fetus. Psychiatric symptoms in pregnancy are more common in women with a history of previous psychiatric disorder, and probably also in those with serious medical problems affecting the course of pregnancy, such as diabetes. Although minor affective symptoms are common in pregnancy, serious psychiatric disorders are probably less common than in non-pregnant women of the same age (Vesga-López et al., 2008).

Some women who had chronic psychological problems before being pregnant report improvement in these problems during pregnancy, while others require extra psychiatric care. The latter are often late or poor attendees at antenatal care, thus increasing the risk of obstetric and psychiatric problems. Misuse of alcohol, opiates, and other substances should be strongly discouraged in pregnancy, especially in the first trimester when the risk to the fetus is greatest (see p. 514). Eating disorders do not appear to be precipitated by pregnancy, and bulimic symptoms may improve.

Great care must be taken in the use of psychotropic drugs during pregnancy and while breastfeeding (see Chapter 19, p. 514).

Hyperemesis gravidarum

About 50% of all pregnant women experience nausea and vomiting in the first trimester. Some authors have suggested that these symptoms, as well as the severe condition of hyperemesis gravidarum, are primarily of psychological aetiology, but this has not been established. However, it is possible that psychological factors influence the severity and course of the symptoms.

Pseudocyesis

Pseudocyesis is a rare condition in which a woman believes that she is pregnant when she is not, and develops amenorrhoea, abdominal distension, and other changes similar to those of early pregnancy. The condition is more common in younger women. Pseudocyesis usually resolves quickly once it has been diagnosed, but some patients persist in believing that they are pregnant. Recurrence is common. Only rarely is the condition associated with a psychiatric disorder.

Couvade syndrome

In this syndrome, the husband of the pregnant woman reports that he is himself experiencing some of the symptoms of pregnancy. This condition may occur in the early months of the woman’s pregnancy, when the man most commonly complains of nausea and morning sickness, and often of toothache. These complaints generally resolve after a few weeks.

Termination of unwanted pregnancy

In the past, psychiatrists in the UK were often asked to see pregnant women who were seeking a therapeutic abortion on the grounds of mental illness. The provisions of current legislation in the UK and many other countries now make it generally more appropriate for decisions to be made by the family doctor and the gynaecologist, without involving a psychiatrist. Nevertheless, psychiatric opinions are still sought at times, not only about the grounds for termination of pregnancy but also for an assessment of the likely psychological effects of termination in a particular patient. Most of the evidence suggests that the psychological consequences of termination are usually mild and transient (Fergusson et al., 2009). For a discussion of termination after genetic testing, see p. 408.

In-vitro fertilization (IVF)

Rates of IVF have increased dramatically over the last two decades. The process is often protracted and anxiety provoking. It is associated with a noticeably increased rate of depression for both partners, rising to 10–25% in the women (Verhaak et al., 2007).

Spontaneous abortion

Approximately 20% of diagnosed pregnancies do not progress beyond 20 weeks, mainly because of fetal defects. Distress is common after miscarriage, although most women improve rapidly (Broen et al., 2005).

Antenatal death

Antenatal death (stillbirth) causes an acute bereavement reaction and, for some women, long-term psychiatric problems, as well as concern about future pregnancy. It is believed by many midwives that parents should be helped to mourn by encouraging them to see and hold the baby, to name it, and to have a proper funeral. However, recent evidence contradicts this, with higher rates of post-traumatic stress disorder in those who follow this advice than in those who do not (Turton et al., 2009). Parents may need some continuing support, and the next pregnancy may be a particularly worrying time.

Caesarean section

Caesarean section has been said to have adverse psychological consequences for parents and infants. Most of the research has failed to test this association because it has not separated the effects of surgery from other adverse factors. However, it would seem sensible to pay particular attention to parental support and to initial bonding.

For a review of the psychiatric aspects of pregnancy, see Brockington (2009).

Postpartum mental disorders

These disorders can be divided into minor mood disturbance (maternity blues), puerperal psychosis, and chronic depressive disorders of moderate severity.

Minor mood disturbance (‘maternity blues’)

Among women who give birth to a normal child, between half and two-thirds experience brief episodes of irritability, lability of mood, and episodes of crying. Lability of mood is particularly characteristic, taking the form of rapid alternations between euphoria and misery. The symptoms reach their peak on the third or fourth day postpartum. Patients often speak of being ‘confused’, but tests of cognitive function are normal. Although they are frequently tearful, patients may not be feeling depressed at the time, but tense and irritable.

‘Maternity blues’ are more frequent among primigravida. The condition is not related to complications at delivery or to the use of anaesthesia. ‘Blues’ patients have often experienced anxiety and depressive symptoms in the last trimester of pregnancy. They are also more likely to give a history of premenstrual tension, fears about labour, and poor social adjustment.

Both the frequency of the emotional changes and their timing suggest that maternity blues may be related to readjustment in hormones after delivery, although this has not been established. No treatment is required because the condition resolves spontaneously within a few days.

Postpartum psychosis

In the nineteenth century, puerperal and lactational psychoses were thought to be specific entities distinct from other mental illnesses (Esquirol, 1845). Later psychiatrists such as Bleuler and Kraepelin regarded the puerperal psychoses as no different from other psychoses. This latter view is widely held today.

Epidemiology

The incidence of postpartum (puerperal) psychoses has been estimated in terms of admission rates to psychiatric hospital (Kendell et al., 1987). The reported rates vary, but a representative figure is one admission per 500 births. This incidence is substantially above the expected rate for psychoses in non-puerperal women of the same age. Puerperal psychoses are more frequent in primiparous women, in those who have suffered previous major psychiatric illness, in those with a family history of mental illness, and probably in unmarried mothers. There is no clear relationship between psychosis and obstetric factors. Puerperal illnesses are reported to be more common in developing than in developed countries, and the excess may be of cases with an organic aetiology. There has been a marked decline in the incidence of puerperal psychosis in the UK, which may be related to the increase in age at the time of first pregnancy.

Aetiology

The early onset of puerperal psychoses has led to speculation that they might be caused by hormonal changes such as those discussed above in relation to the blues syndrome. However, there is no evidence that hormonal changes in women with puerperal psychoses differ from those in other women in the early puerperium. Therefore if endocrine factors do play a part, they would seem to act only as precipitating factors in predisposed women. There are genetic factors, related to those involved in bipolar disorder, with linkage reported to chromosome 16 (Jones et al., 2007). The risk is 20–30% with an established diagnosis of bipolar disorder, rising to 57% with a prior diagnosis and a family history.

Clinical features

The onset of puerperal psychosis is usually within the first 1–2 weeks after delivery, but rarely it occurs within the first 2 days. Three types of clinical picture are observed—delirium, mood disorder, and schizophreni-form disorder. Delirium was common in the past, but has become much less frequent since the incidence of puerperal sepsis was reduced by antibiotics. Nowadays mood disorders predominate (either bipolar disorder or schizo-affective disorder). Schizophreniform disorders presenting for the first time are rare. The clinical features of these syndromes are generally regarded as being much the same as those of the corresponding non-puerperal syndromes. Insomnia and overactivity are often early features. Perplexity and confusion are common.

Management

Assessment

Assessment should be prompt and must pay attention to the potential risks to mother and baby (Spinelli, 2009). As well as the usual psychiatric assessment, it is essential to ascertain the mother’s ideas concerning the baby. Severely depressed patients may have delusional ideas that the child is malformed or otherwise imperfect. These false ideas may lead to attempts to kill the child to spare it from future suffering. Patients with schizophrenia may also have delusional beliefs about the child—for example, they may be convinced that the child is abnormal or evil. Again, such beliefs may lead to the risk of an attempt to kill the child. Patients with depression or schizophrenia may also make suicide attempts.

Treatment

This is given according to the clinical syndrome, as described in other chapters. Admission to hospital is normally required. It has been argued that this should be in a special mother and baby unit where the child can remain with the mother in order to minimize adverse effects on maternal bonding. Once the admission has been arranged, all contacts between the mother and baby should be supervised at first by nursing staff, and thereafter reviewed in the light of clinical progress.

Electroconvulsive therapy (ECT) is often the best treatment for patients with depressive or manic disorders of marked or moderate severity, because it is rapidly effective and enables the mother to resume the care of her baby quickly. For less urgent depressive disorders, antidepressant medication may be tried first. If the patient has predominantly schizophrenia-like symptoms, an antipsychotic drug may be prescribed. If definite improvement does not occur within a short period, ECT should be considered, especially if the onset was acute.

Prognosis

Most patients recover fully from a puerperal psychosis, but some of those with a schizophrenic disorder remain chronically ill. After subsequent childbirth the recurrence rate for depressive illness in the puerperium is approximately 20–30%. According to Protheroe (1969), at least 50% of women who have suffered a puerperal depressive illness will later suffer a depressive illness that is not puerperal. All mothers who have suffered postpartum psychosis should be considered for special psychiatric review during any further pregnancies, so that postpartum problems can be identified early and treated promptly and effectively.

Postnatal depression of mild or moderate severity

Less severe depressive disorders are much more common than the puerperal psychoses, occurring in 10% of women in the early weeks postpartum. Tiredness, irritability, and anxiety are often more prominent than depressive mood change, and there may be phobic symptoms. Most patients recover after 2 to 6 months.

Aetiology

Clinical observation suggests that these disorders are often precipitated in vulnerable mothers by the psychological adjustment required after childbirth, as well as by the loss of sleep and the hard work involved in the care of the baby. There is little evidence of a biological basis. The main risk factors are a previous history of depression (especially when accompanied by obstetric complications) and indications of social adversity.

Management

Despite the medical and other care that is given to women after childbirth, many postpartum depressions go undetected or, if they are detected, remain untreated. Therefore those providing care for the mother and baby need to be alert to the possibility of depression. In treatment, psychological and social measures are usually as important as antidepressant drugs. Most women can be treated effectively in primary care with support, including help with solving practical problems. A small proportion need antidepressant medication, and a few with severe or complex problems require referral to the psychiatric services.

Effects on the child

Postnatal depression adversely affects the infant’s relationship with its mother, as well as its early cognitive and emotional development (Stein et al., 1991). Evidence of negative consequences later in childhood is less clear.

For a review of postnatal depression, see Cooper and Murray (1998). For reviews of all aspects of postpartum psychological complications, see Brockington (1998, 2000). For a review of psychopharmacology during pregnancy and the postpartum period, see Viguera and Cohen (2000) and Chapter 19.

Psychiatric aspects of gynaecology

Premenstrual syndrome

This term denotes a group of psychological and physical symptoms that start a few days before and end shortly after the onset of a menstrual period. The psychological symptoms include anxiety, irritability, food cravings, and depression, and the physical symptoms include breast tenderness, abdominal discomfort, and a feeling of distension. Premenstrual syndrome is not included in current classifications of psychiatric disorder, although premenstrual dysphoric disorder is listed as a condition for future study in DSM-IV. The syndrome should be distinguished from the much more frequent occurrence of similar symptoms that are not strictly premenstrual in timing.

Epidemiology

Estimates of the frequency of the premenstrual syndrome in the general population vary widely (30–80% of women of reproductive age). There are three main reasons for this wide variation. First, there is a problem of definition. Mild and brief symptoms are frequent premenstrually, and it is difficult to decide when they should be classified as premenstrual syndrome. Secondly, information about symptoms is often collected retrospectively by asking women to recall earlier menstrual periods, and this is an unreliable way of establishing the time relationships. Thirdly, the description of premenstrual symptoms is subjective, and may be influenced by knowledge that the enquiry is concerned specifically with the premenstrual syndrome.

Aetiology

The aetiology is uncertain. Biological explanations have been based on ovarian hormones (excess oestrogen, lack of progesterone), pituitary hormones, and disturbed fluid and electrolyte balance. None of these theories has been proved. Various unproven psychological explanations have been based on possible associations of the syndrome with neuroticism or with attitudes towards menstruation.

Treatment

The syndrome has been widely treated with progesterone, and also with oral contraceptives, bromocriptine, diuretics, and psychotropic drugs. There is no convincing evidence that any of these is effective, and treatment trials suggest a high placebo response rate (up to 65%). Psychological support and encouragement may be as helpful as medication. There have been encouraging reports of the effectiveness of SSRI antidepressants during the vulnerable period, and some less certain evidence for cognitive–behavioural treatment (Lustyk et al., 2009).

For a review of the syndrome and its treatment, see O’Brien et al. (2011).

The menopause

In addition to the physical symptoms of flushing, sweating, and vaginal dryness, menopausal women often complain of headache, dizziness, and depression. It is not certain whether depressive symptoms are more common in menopausal women than in non-menopausal women. Nevertheless, among patients who consult general practitioners because of emotional symptoms, a disproportionately large number of women are in the middle-age group that spans the menopausal years.

Depressive and anxiety-related symptoms at the time of the menopause could have several causes. Hormonal changes have often been suggested, notably deficiency of oestrogen. In some countries, in particular the USA, oestrogen has been used to treat emotional symptoms in women of menopausal age, but the results of trials of treatment with oestrogens remain preliminary (Ancelin et al., 2007). Psychiatric symptoms at this time of life could equally well reflect changes in the woman’s role as her children leave home, her relationship with her partner alters, and her own parents become ill or die. It seems best to treat depressed menopausal women with methods that have been shown to be effective for depressive disorder at any other time of life.

Hysterectomy

Several retrospective studies have indicated an increased frequency of depressive disorder after hysterectomy. An important prospective investigation using standardized methods (Gath et al., 1982a,b) showed that patients who are free from psychiatric symptoms before hysterectomy seldom develop them afterwards. Some patients with psychiatric symptoms before hysterectomy lose them afterwards, but in other individuals these symptoms persist. It is likely that the latter group, who have symptoms before and after surgery, are identified in the retrospective studies, leading to the erroneous conclusion that hysterectomy causes depressive disorder. This finding illustrates the need for a general warning about inferring the effects of treatment from the results of retrospective investigations.

Sterilization

Considerations similar to those for hysterectomy apply to these procedures. Although retrospective studies suggested that sterilization leads to psychiatric disorder and sexual dysfunction, prospective enquiry has contradicted this. Indeed sexual relationships are more likely to improve than worsen, and definite regrets are reported by less than one in 20 women.

For reviews of the psychological aspects of gynaecology, see Robinson (2000) and Brockington (2000).

Further reading

Gelder MG, Andreasen NC, López-Ibor JJ Jr and Geddes JR (eds) (2009). The New Oxford Textbook of Psychiatry. Oxford University Press, Oxford. (See Sections 4.6.3, 4.9, and Section 5 on psychiatry and medicine by various authors.)

Mayou R, Sharpe M and Carson A (2003). ABC of Psychological Medicine. BMJ Books, London. (A collection of brief practical reviews.)