Current Themes in Psychiatry in Theory and Practice

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Selection and editorial matter © Niruj Agrawal, Jim Bolton and
Raghunandan Gaind 2012
Chapters © their individual authors 2012
Foreword © George Ikkos 2012
Softcover reprint of the hardcover 1st edition 2012 978-0-230-53529-9
All rights reserved. No reproduction, copy or transmission of this
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in accordance with the Copyright, Designs and Patents Act 1988.
First published 2012 by
PALGRAVE MACMILLAN
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registered in England, company number 785998, of Houndmills, Basingstoke,
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ISBN 978-1-349-35827-4 ISBN 978-0-230-31706-2 (eBook)
DOI 10.1057/9780230317062
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A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Current themes in psychiatry in theory and practice / edited by Niruj
Agrawal, Jim Bolton, Raghunandan Gaind.
p. ; cm.
Includes bibliographical references and index.

1. Psychiatry. 2. Mental illness. I. Agrawal, Niruj. II. Bolton, Jim, 1965–

III. Gaind, Raghunandan [DNLM: 1. Psychiatry. 2. Mental Disorders. WM 100]
RC454.C826 2011
616.89—dc23 2011013735
10 9 8 7 6 5 4 3 2 1
21 20 19 18 17 16 15 14 13 12
The Practice of medicine is an art not trade, a calling, not a
business. A calling in which your heart will be exercised equally
with your head.
Sir William Osler, 1903
Contents

List of Tables ix

List of Figures x

List of Boxes xi

List of Abbreviations xii

Preface xvi

Foreword xix

Notes on Editors xx

Notes on Contributors xxi

Part I Issues of Contemporary Concern

1 Culture and Mental Health 3
Dinesh Bhugra and Norman Poole

2 Public Health Psychiatry in Criminal Justice States 18

Jaydip Sarkar

3 Younger People with Dementia 37

Kate Jefferies, Robert Lawrence and Niruj Agrawal

4 Substance Misuse and Comorbid Psychiatric Disorders 57

Sanjoo Chengappa and Mohammed T. Abou-Saleh

5 Acute and Transient Psychotic Disorders 77

Swaran P. Singh

Part II Interface of Medicine and Psychiatry

6 Symptoms Unexplained by Disease 101
Alan Carson and Jon Stone

7 Psychological Conceptualisation and Treatment

Approaches to Functional Non-Epileptic Attacks 129
Danielle Gaynor and Niruj Agrawal

vii
viii Contents

8 Gilles de la Tourette Syndrome 148

Jeremy S. Stern and Mary M. Robertson
9 Depression in Physical Illness 166
Audrey Ng and Steven Reid

10 Physical Consequences of Eating Disorders 185

Kate Webb, J. Hubert Lacey and John Morgan

Part III Therapeutic Challenges

11 Neuroleptic-Induced Movement Disorders: Past and Present 207
Marie-Hélène Marion

12 The Clinician’s Role in Helping Patients to Take

Antidepressants as Prescribed 219
Alex J. Mitchell

13 Borderline Personality Disorder: Causal Factors,

Diagnosis and Treatment 237
Daniel C. Riordan and Pat Hughes

14 Biofeedback in Psychiatric Practice 252

Kishore Chandiramani

Index 267
Tables

3.1 Bedside tests of frontal lobe function 41

3.2 Primitive reflexes 42
3.3 Antidementia agents 53
4.1 Dual diagnosis: a review of aetiological theories 60
4.2 Treatment interventions 66
5.1 Comparison of remitting psychotic disorders in
the ICD-10 and DSM-IV 86
6.1 Symptoms and syndromes unexplained by disease in
different medical specialties 104
6.2 Attack features that can help to distinguish
non-epileptic attacks from epileptic seizures 113
6.3 A scheme for thinking about the aetiology of
functional symptoms in neurology 116
7.1 Common causes of non-epileptic attacks 131
9.1 Use of antidepressants in selected medical disorders 180
14.1 Disorders and therapeutic modalities used 255

ix
Figures

3.1 Prevalence of dementia by age 39

3.2 Distribution of diagnoses in young-onset dementia 39
3.3 Distribution of diagnosis of dementia occurring in later life 40
3.4 MRI scan of CADASIL 46
3.5 Clinical syndromes related to frontotemporal dementia 47
4.1 Substance misuse and mental illness 58
4.2 COMPASS programme 67
6.1 The proportion of symptoms in primary care
explained by disease 104
6.2 Misdiagnosis is no more common than for other
neurological and psychiatric disorders 105
6.3 Hoover’s sign to test for functional weakness 111
6.4 Hemisensory disturbance 112
6.5 A composite scan of four patients with functional
hemimotor and sensory symptoms compared to recovery 117
6.6 Diagnostic labels can be inherently offensive 119
6.7 A cognitive-behavioural model showing targets
for treatment 123
9.1 Prevalence of major depression in self-reported,
long-term medical conditions 167
10.1 Algorithm for referral 187
12.1 A new nosology of medication adherence 220
12.2 Frequency of clinician advice about
starting antidepressants 230

x
Boxes

3.1 NINCDS/ADRDA criteria for the clinical diagnosis of

probable Alzheimer’s disease 44
3.2 NINDS criteria for frontal lobe dementia – core
diagnostic criteria 48
3.3 Symptoms of frontal lobe dysfunction 48
3.4 Rapid eye movement sleep behaviour disorder (RBD) 49
3.5 Behavioural analysis: ABC charts – ‘antecedent,
behaviour and consequences’ 54
4.1 Principles of treatment of substance misuse in people
with severe mental illness 63
7.1 Clinical features suggestive of FNEA 132
7.2 Common clinical presentations of FNEA 133
7.3 Aetiological factors for FNEA 136
8.1 DSM-IV-TR diagnostic criteria for Tourette syndrome 149
8.2 Management of Tourette syndrome 158
9.1 Depression and associated poor physical outcome 168
9.2 Physical illnesses and drugs commonly associated
with depression 169
9.3 Criteria for diagnosis of depression 171
11.1 Neuroleptic-induced movement disorders that
disappear after stopping the neuroleptic 208
11.2 Neuroleptic-induced movement disorders that
can persist after stopping the neuroleptic 208
11.3 Risk factors associated with tardive dyskinesias 211
11.4 Risk factors associated with acute and tardive dystonia 211
11.5 The most common conditions, other than
schizophrenia, treated with atypical neuroleptics 213
11.6 Treatment of tardive dyskinesias 215
12.1 Types of poor medication adherence 222
12.2 Summary of predictors of missed
antidepressant medication 224
12.3 Basic strategies to enhance concordance 227
12.4 Advanced strategies to improve concordance 227
12.5 Clinician advice when starting antidepressants 230
14.1 Contraindications of biofeedback therapy 255
14.2 Parameters of stress that can be measured 256

xi
Abbreviations

ABGA anti-basal ganglia antibodies

ACE Addenbrooke’s Cognitive Examination
ACTH adrenocorticotrophic hormone
ADHD attention deficit hyperactivity disorder
ADR acute dystonic reaction
ADRDA Alzheimer’s Disease and Related Disorders Association
AIDS acquired immune deficiency syndrome
AIREN Association Internationale pour la Recherche et
l’Enseignment en Neurosciences
ANS autonomic nervous system
ASD autistic spectrum disorder
ATPD acute and transient psychotic disorder
BAD bipolar affective disorder
BDI Beck Depression Inventory
BMI body mass index
BPD borderline personality disorder
BSE bovine spongiform encephalopathy
CADASIL cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalography
CBT cognitive-behavioural therapy
CD conduct disorder
CI confidence interval
CJD Creutzfeldt–Jakob disease
CMT chronic motor or vocal tic disorder
CNS central nervous system
COMPASS Combined Psychosis and Substance Use Programme
COPD chronic obstructive pulmonary disease
CREATE Cardiac Randomized Evaluation of Antidepressant and
Psychotherapy Efficacy
CSF cerebrospinal fluid
CSM Committee on Safety of Medicines
CT computed tomography
CYP cytochrome P450
DAT-SPECT dopamine transporter single proton emission computed
tomography

xii
 List of Abbreviations xiii

DBS deep brain stimulation

DBT dialectical behaviour therapy
DEXA dual x-ray absorptiometry
DOP dangerous offender provisions
DOSMED Determinants of Outcome of Serious Mental Disorders
Study
DSM Diagnostic and Statistical Manual of Mental Diseases
DSPD Dangerous and Severe Personality Disorder (initiative)
ECG electrocardiography/electrocardiographic
ECT electroconvulsive therapy
EDNOS eating disorders not otherwise specified
EEG electroencephalogram/electroencephalography
EMG electromyogram/electromyography
EOG electro-oculography
ENRICHD Enhancing Recovery in Coronary Heart Disease (trial)
EPS extrapyramidal symptoms
ESR erythrocyte sedimentation rate
FBC full blood count
FLAIR fluid attenuated inversion recovery
fMRI functional magnetic resonance imaging
FNEA functional non-epileptic attacks
FTD frontotemporal dementia
GABA gamma amino butyric acid
GABHS group A beta-haemolytic streptococcus
GHQ General Health Questionnaire
GSR galvanic skin response
HAART highly active antiretroviral therapy
HCR-20 Historical Clinical Risk-20
5-HIAA 5-hydroxyindole acetic acid
HIV human immunodeficiency virus
HMPAO hexamethylpropyleneamine oxime
HRT habit-reversal training
HRV heart-rate variability
ICD International Classification of Diseases
IHCIS Integrated Healthcare Information Services
IPD idiopathic Parkinson’s disease
IPP Indeterminate Public Protection (order)
IPSS International Pilot Study of Schizophrenia
IR International Registry
ITU intensive therapy unit
LFT liver function test
xiv List of Abbreviations

LIT local implementation team

LSP language-support programme
MAOA monoamine oxidase A
MBT mentalisation-based therapy
MET motivational enhancement therapy
MMPI Minnesota Multiphasic Personality Inventory
MMSE mini mental state examination
MND motor neurone disease
MRI magnetic resonance imaging
NA Narcotics Anonymous
NCS-R National Comorbidity Survey replication
NEAD non-epileptic attack disorder
NHS National Health Service
NHSDA National Household Survey on Drug Abuse
NICE National Institute for Health and Clinical Excellence
NINCDS National Institute of Neurological and Communication
Disorders and Stroke
NINDS National Institute of Neurological Disorders and Stroke
NIP neuroleptic-induced parkinsonism
NL neuroleptic
NMDA N-methyl-D-aspartate
NSF National Service Framework
NSMHW National Survey of Mental Health and Wellbeing
OCB obsessive-compulsive behaviour
OCD obsessive-compulsive disorder
OCP oral contraceptive pill
ODD oppositional defiant disorder
PANDAS paediatric autoimmune neuropsychiatric disorders
associated with streptococcal infections
PCL-R revised version of the Psychotherapy Checklist
PD personality disorder
PET positron emission tomography
PHQ Patient Health Questionnaire
PNES psychogenic non-epileptic seizures
PTSD post-traumatic stress disorder
QEEG quantitative EEG
QOL quality of life
QOLAS Quality of Life Assessment Schedule
QTc QT interval corrected for heart rate
RBD rapid eye movement sleep behaviour disorder
RCT randomised controlled trial
 List of Abbreviations xv

REM rapid eye movement

RLS restless legs syndrome
RSA respiratory sinus arrhythmia
SADHART Sertraline Antidepressant Heart Attack Randomized Trial
SAMHSA Substance Abuse and Mental Health Services
Administration
SCAAPS Schedule for the Clinical Assessment of Acute Psychotic
States
SFT schema-focused therapy
SIB self-injurious behaviour
SPECT single proton emission computed tomography
SSRI selective serotonin reuptake inhibitor
T3 tri-iodothyronine
T4 thyroxine
TCA tricyclic antidepressant
TD tardive dyskinesia
TFP transference-focused psychotherapy
TFT thyroid function test
TS Tourette syndrome
TSH thyroid-stimulating hormone
TTD thought-translation device
UK United Kingdom
USA United States of America
UNESCO United Nations Educational, Scientific and Cultural
Organization
vCJD new variant Creutzfeldt–Jakob disease
VRAG Violence Risk Appraisal Guide
WHO World Health Organization
Preface

Psychiatry as a discipline has been growing at an astounding rate inter-

nationally. There has been a rapid expansion of services to meet the
needs of mentally ill people. In parallel, ongoing research has led to a
dramatic explosion of information. It is a formidable task to keep up
to date with knowledge and this is a great challenge for teachers and
clinicians. Current Themes in Psychiatry in Theory and Practice strives to
help trainees and busy clinicians keep abreast of issues of contemporary
concern and therapeutic challenges in clinical psychiatry.
Current Themes in Psychiatryy was published as a series of books from
the late 1970s to the early 1990s under the leadership of its lead edi-
tor Dr Raghunandan Gaind. The book proved useful to psychiatrists
preparing for higher examinations as well as to others in allied disci-
plines with special interest in psychiatry. Volumes 3 and 4 included
more international contributions, particularly from North America, on
varying topics reflecting the developments in modern psychiatry and
examining new psychotherapies.
The core purpose of the current book is to provide a clinically rele-
vant and detailed overview of carefully selected topics. These topics are
often not covered in as much detail by commonly read textbooks and
we hope this book will complement those textbooks. Busy clinicians
and trainees may not have enough time to do their own detailed litera-
ture searches, or may not have access to the vast array of journal articles
that inform various chapters of this book. We have chosen authors who
are leaders in their fields and are experienced clinicians, researchers
and writers. They have used their vast experience and clinical wisdom
to distil the essential information from the published literature to date
and present it in a manner that is easy to follow for the reader whilst
instilling greater insights.
The book consists of 14 chapters covering a wide range of psychiat-
ric topics divided into three sections. Part I focuses on issues of con-
temporary concern including chapters on highly topical and globally
relevant areas such as ‘Culture and Mental Health’ and ‘Public Health
Psychiatry in Criminal Justice States’. In an increasingly shrinking and
globalised world with constant and ongoing migration in all directions,
conceptual knowledge and practical understanding of cultural issues is

xvi
 Preface xvii

a must for all clinicians. The second chapter deals with the conflict that
most psychiatrists face between duty to society and their duty to the
individual. With an ageing society and increasing focus on dementia in
the elderly, there is recognition of glaring gap in knowledge and service
provision for younger people with dementia, which is covered in the
third chapter. Chapters 4 and 5 provide a much needed reconsideration
of the topics of ‘Substance Misuse and Comorbid Psychiatric Disorders’
and ‘Acute and Transient Psychotic Disorders’, which remain a source of
diagnostic and management dilemma globally.
Part II deals with often-overlooked ‘Interface of Medicine and
Psychiatry’. Chapter 6 deals with ‘Symptoms Unexplained by Disease’,
which is a subject everyone finds difficult, and clinically useful infor-
mation is often difficult to come by. The chapter on ‘Functional
Non-epileptic Attacks’ nicely complements the one on ‘Symptoms
Unexplained by Disease’. Chapters on ‘Tourette Syndrome’, ‘Depression
in Physical Illness’ and ‘Physical Consequences of Eating Disorders’
highlight the extensive interface between medicine and psychiatry and
provide readers with practical insights.
Part III focuses on therapeutic challenges and advances in contem-
porary psychiatry. Despite the emergence of a whole range of atypi-
cal antipsychotic drugs with promise of no extrapyramidal side effects,
the topic of ‘Neuroleptic-induced Movement Disorders’ remains as rel-
evant as ever. The challenge of helping patients to take medications
as prescribed is felt by clinicians worldwide and is nowhere else more
acute than in the area of antidepressant prescribing, as discussed in
Chapter 12. Emerging treatments in two very different areas are dis-
cussed in the last two chapters: ‘Borderline Personality Disorder’ and
‘Biofeedback in Psychiatric Practice’, providing readers with an over-
view as well as necessary clinical understanding.
We believe this book will help in guiding psychiatry students world-
wide. It will also be a useful resource for busy psychiatrists in day-to-
day clinical practice, and for other medical and allied professionals
such as general practitioners, psychologists, mental health nurses
and social workers, to name a few. We hope the variety of chapters
included will enhance and stimulate clinicians and lead to a better
clinical care.
We are grateful for the encouragement and practical advice we have
received throughout from Dr Raghunandan Gaind, founder of the orig-
inal series to whom this book is dedicated. This book would not have
been possible without the help and support of many people. We would
like to thank all the authors for their outstanding contributions, which
xviii Preface

are both scholarly and easy to read. We have the pleasure of knowing
them all and working with many of them. We are grateful to Olivia
Middleton, Associate Editor at Palgrave Macmillan, for her support and
friendly advice, and Rebecca Ewens for proof reading. Thank you to our
families for their constant support during the editing and production
of this book.

Niruj Agrawal and Jim Bolton