Core Clinical Cases in Psychiatry A problem-solving approach PDF

Preface

This book aims to present undergraduate medical students with clinical case scenarios that are common in psychiatric practice, and take them through a process of assessment and diagnosis, identifying likely aetiological factors, and considering appropriate treatment options. It has been informed by changes in undergraduate medical education at a national level that are increasingly impacting on the way in which clinical skills are evaluated.

The process of clinical assessment is a little different in psychiatry from other branches of medicine. In psychiatry, all diagnoses are syndromal. Diagnosis depends on the doctor being able to understand clearly a patient's subjective experience, to categorize those experiences in psychopathological terms, and then to recognize those collections of symptoms which go to form recognized syndromes. Physical investigations remain important in psychiatry, but not usually to confirm a diagnosis. Rather, they may be used to exclude physical diagnoses or to support pharmacological treatment. Therefore, for each case in the book, with the exception of Chapter 4 in the Clinical cases section, the first question asks for a differential diagnosis and the second question considers the clinical features which may help to confirm this.

Psychiatric treatment may be diagnosis-specific, for example, antidepressant treatment for a depressive episode. However, in many cases the most appropriate forms of treatment are determined by other factors which are considered to have contributed to the illness. So, a patient with schizophrenia is likely to require treatment with an antipsychotic drug, but other treatments may depend on whether their psychosis has been precipitated by substance misuse, by high expressed emotion in the family, or by poor compliance with maintenance antipsychotic medication. Therefore, as well as making a diagnosis it is necessary to consider aetiological factors, which may represent targets for therapeutic intervention. Question 3 of the Clinical cases section relates to aetiology. This book uses the following terms:

• Predisposing factors: These are things which lead to an individual having an increased likelihood of developing a particular illness. Often, they are epidemiologically observed associations.
• Precipitating factors: These are factors which have contributed to causing an individual to develop an illness at a particular time.
• Maintaining factors: These are factors which may be preventing a patient from recovering, or may be reducing the effectiveness of treatment. Often, there is some overlap between maintaining factors and precipitating factors.

Issues related to culture and diversity are also particularly important in psychiatric assessment and treatment. The presentation of mental illness often reflects cultural beliefs and customs, and the acceptability of certain treatment modalities may also be affected by culturally determined characteristics.

The fourth question relating to each case discusses treatment options. One of the first considerations is often to decide on the location of treatment – that is, whether it can be carried out in the community or whether it is necessary to admit a patient to hospital. The decision to admit to hospital usually depends on the extent to which:

• The illness is interfering with a patient's functioning at home.
• Their health may deteriorate without rapid treatment or nursing care.
• They may pose a risk to themselves or to other people.

Treatment options are then considered in terms of physical treatments, psychological treatments and social treatments. In most cases, all three of these are important.

The final question asks about prognosis and the likely course of the disorder. Many psychiatric disorders have a wide range of prognoses. It is important to have a clear knowledge of those factors that may allow you to make judgements about prognosis in individual cases, so that you can educate and inform patients, and make appropriate decisions with regard to ongoing treatment.

The questions in the Clinical cases section of Chapter 4 are different. This chapter is specifically concerned with managing chronic disorders. Therefore, the diagnoses are given and the questions only ask about the three forms of treatment – physical, psychological and social.

The OSCE counselling questions ask how to approach other forms of common clinical situations, perhaps involving discussions with patients or their carers, or liaison with other medical specialties. These important aspects of clinical practice are increasingly being tested in clinical examinations.