Psychiatry, clinical cases uncovered peter byrne, nicola byrne

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  2. 2. PsychiatryCLINICAL CASES UNCOVEREDPeter ByrneMA, MB, MRCPsychConsultant Liason PsychiatristNewham University HospitalLondonNicola ByrneMBChB, BSc, MSc, MRCPsychConsultant PsychiatristLambeth Adult Mental HealthThe Maudsley HospitalLondonA John Wiley & Sons, Ltd., Publication
  3. 3. This edition fi rst published 2008, 2008 by P. Byrne and N. ByrneBlackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwellspublishing program has been merged with Wileys global Scientifi c, Technical andMedical business to form Wiley-Blackwell.Registered offi ce: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, WestSussex, PO19 8SQ, UKEditorial offi ces: 9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK111 River Street, Hoboken, NJ 07030-5774, USAFor details of our global editorial offi ces, for customer services and for informationabout how to apply for permission to reuse the copyright material in this book pleasesee our website at right of the author to be identifi ed as the author of this work has been asserted inaccordance with the Copyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical,photocopying, recording or otherwise, except as permitted by the UK Copyright,Designs and Patents Act 1988, without the prior permission of the publisher.Wiley also publishes its books in a variety of electronic formats. Some content thatappears in print may not be available in electronic books.Designations used by companies to distinguish their products are often claimed astrademarks. All brand names and product names used in this book are trade names,service marks, trademarks or registered trademarks of their respective owners. Thepublisher is not associated with any product or vendor mentioned in this book. Thispublication is designed to provide accurate and authoritative information in regard tothe subject matter covered. It is sold on the understanding that the publisher is notengaged in rendering professional services. If professional advice or other expertassistance is required, the services of a competent professional should be sought.Library of Congress Cataloguing-in-Publication DataByrne, Peter, MA.Psychiatry : clinical cases uncovered / Peter Byrne, Nicola Byrne.p. ; cm.Includes index.ISBN 978-1-4051-5983-81. PsychiatryExaminations, questions, etc. 2. PsychiatryCase studies. I. Byrne,Nicola. II. Title.[DNLM: 1. Mental DisordersProblems and Exercises. WM 18.2 B995p 2008]RC465.B97 2008616.890076dc222008009431ISBN: 978-1-4051-5983-8A catalogue record for this book is available from the British LibrarySet in 9/12pt Minion by SNP Best-set Typesetter Ltd., Hong KongPrinted in Singapore by COS Printers Pte Ltd1 2008
  4. 4. ContentsIntroduction, viiHow to use this book, xPart 1 Basics, 1Approach to the patient, 1Mental health treatments, 12Part 2 Cases, 36Case 1 A 20-year-old student who collapses in the supermarket, 36Case 2 A 47-year-old woman who lives in fear that God will punish her, 44Case 3 An 18-year-old college drop-out gets an eviction order from his parents, 52Case 4 An 18-year-old trainee chef who cannot go to work, 59Case 5 Sudden deterioration of a 78-year-old woman in a nursing home, 66Case 6 A 72-year-old woman with antisocial behaviour, 74Case 7 A 64-year-old retired teachers depression is getting worse, 81Case 8 A 17-year-old man has been cutting his arms, 88Case 9 A 9-year-old disruptive child faces expulsion from school, 96Case 10 A 48-year-old security guard with new symptoms every day, 104Case 11 A 28-year-old man has been arrested at the airport, 111Case 12 A 24-year-old new mother in distress, 119Case 13 A 15-year-old head prefect with pneumonia is behaving secretly, 128Case 14 Insomnia in a 26-year-old successful City man, 135Case 15 A 15-year-old child assaults his foster mother, 143Case 16 A 42-year-old woman insists she is pregnant, 150Case 17 The wife of a 66-year-old GP with Parkinsons disease is worried about him, 157Case 18 Complete loss of memory in a fi t middle-aged man, 164v
  5. 5. Case 19 A 32-year-old woman puts her GP under pressure, 171Case 20 The 21-year-old critical medical student, 182Case 21 A 24-year-old legal secretary with depressed mood and suicidal thoughts, 188Case 22 A 41-year-old woman with epilepsy develops a different pattern of fi ts, 195Part 3 Self-assessment, 203MCQs, 203EMQs, 207SAQs, 211Answers, 214Index of cases by diagnosis, 223Index, 224vi Contents
  6. 6. IntroductionPsychiatry is the ultimate clinical speciality. No otherbranch of medicine relies so much on empathic listeningskill and the integration of biological, psychological andsociological theory to unravel a patients story into acoherent aetiological formulation. Whether you hope tocall yourself a psychiatrist or are just passing through, beaware that this is a golden opportunity to acquire com-petenciesthat will serve as foundations for your workinglife (e.g. understanding reactions to illness and adversity,the relationships between physical and mental health,working with diffi cult patients and relatives, and keepingyour cool in unpredictable situations).The focus throughout the book is on developing yourclinical reasoning and core competencies up to a stan-dardof passing undergraduate examinations, workplace-basedassessments of your early years as a doctor, andbeyond. Part 1 is a guide to psychiatric assessment andintroduces the range of treatment options, Part 2 is acollection of case studies covering the range of mentaldisorders, and Part 3 is for self-assessment. Ultimately,clinical judgement comes from experience, and the morepatients you encounter, the more skilled you will become.Some clinical dilemmas have no textbook right answer.Medical professionalism is based on working within ourshared ethical framework (Box A); whenever the rightsand wrongs of a situation are opaque, it can be helpfulto return to these fi rst principles to determine youraction.You will get the most from the case studies by stoppingto answer every question posed as the responsible doctor.The cases vary in complexity, beginning with easier ones.An index of cases by diagnosis is provided on p. 223 useful for revision or if you want to select a case forpeer group learning or tutorials. All cases are amalgamsof patients and situations we have come across, and nonedescribe identifi able individuals.In relation to diagnoses, we have used the WorldHealth Organizations categorization of mental disorder,the ICD-10 (International Classifi cation of Diseases).Box A The duties of a doctorThe terms here are used to describe disorders, not people:people with borderline personality disorders or schizo-phreniaare not borderlines or schizophrenics.viiPatients must be able to trust doctors with their lives andhealth (General Medical Council: Tojustify that trust you must show respect for human lifeand you must: Make the care of your patient your fi rst concern Protect and promote the health of patients and thepublic Provide a good standard of practice and care Keep your professional knowledge and skills up to date Recognize and work within the limits of yourcompetence Work with colleagues in the ways that best servepatients interests Treat patients as individuals and respect their dignity Treat patients politely and considerately Respect patients right to confi dentiality Work in partnership with patients Listen to patients and respond to their concerns andpreferences Give patients the information they want or need in away they can understand Respect patients right to reach decisions with youabout their treatment and care Support patients in caring for themselves to improveand maintain their health Be honest and open and act with integrity Act without delay if you have good reason to believethat you or a colleague may be putting patients at risk Never discriminate unfairly against patients or colleagues Never abuse your patients trust in you or the publicstrust in the professionYou are personally accountable for your professionalpractice and must always be prepared to justify yourdecisions and actions.
  7. 7. Diagnoses do not defi ne identity, and they need to beused sensitively in mental health.We have both been lucky enough to learn throughgreat clinicians we have been taught by and worked with,and from the generosity of our patients. None of us canfully understand what something is like until we experi-enceit ourselves, and fi rst-hand accounts of mental dis-ordersthat we have found valuable are listed in Furtherreading below. You will not need them to pass exams, butthey are worth reading to balance your clinical experi-enceand reading with the realities of mental illness andits consequences.Peter and Nicola Byrne2008Further readingSunbathing in the Rain: A Cheerful Book about Depression.Gwyneth Lewis (2007) HarperCollins. The author is apoet, and her experience of a severe depressive episodeis charted as her investigation into the mystery of howshe came to arrive at the point of psychological col-lapse.She re-evaluates assumptions about depressionas simply a problem, exploring its meaning for her andits potential role as a signal that her life needed tochange. Comprising a series of short sections whichcan be dipped into, she speaks to those involved incaring for depressed people, and those currentlydepressed themselves and unable to digest long tractsof text.An Unquiet Mind. Kay Redfi eld Jamison (1995) Vintage.A psychiatric classic, the author is an eminentAmerican professor of psychiatry who describes herexperience of bipolar affective disorder. Withfrequent intersections between the personal and thescientifi c, it is widely read by professionals andp