Homicide

A range of killings of one person by another can be described as a homicide. Homicide rates vary greatly between geographic regions, reflecting differences in social factors such as weapon availability, patterns of substance use, the efficacy of the police and other institutions, and overall levels of violent crime. Domestic homicide is killing within a family and includes fatal domestic violence and most homicides of infants, children, and older people. Most homicides by people with mental illness are of family members, but most domestic homicide offenders are not mentally ill. People with mental illness, particularly those with schizophrenia, commit a small percentage of all homicides, but a disproportionate number, compared to the incidence of mental illness. Mental health professionals have a role in preventing homicides by offering interventions for domestic violence, substance use disorder, and the early and continued treatment of psychotic disorders.

The expert witness in the criminal and civil courts

The psychiatric expert witness in court acts at the interface between psychiatry and the law. This chapter explores the legal, ethical, and procedural frameworks for this work, with special reference to the criminal court in common law jurisdictions.

Stalking and querulous behaviour

Stalking and querulousness describe problem behaviours characterized by persistently pursuing a person or a cause in such a manner, or to such an extent, that the behaviour creates fear, distress, or disruption to those involved or targeted. An obvious obsessive or fixated quality is associated with both behaviours, and personality traits of rigidity and rumination are frequently observed, though the state of mind rarely conforms to that found in obsessional disorders. Stalkers and querulants rarely regard their behaviour as unjustified, let alone irrational, and few see their persistence as senseless. They may resist the impulse or urge to pursue their victims or cause on occasion but, for the most part, devote themselves wholeheartedly to their objectives. This chapter explores the epidemiology ad phenomenology of stalking and querulousness and the role of (forensic) psychiatry in responding not only to the perpetrators of these behaviours, but also to the unfortunate victim’s of their disordered attention.

Treatment of fibromyalgia (chronic widespread pain) and chronic fatigue syndrome

Fibromyalgia (FM), one of the chronic widespread pain syndromes, and chronic fatigue syndrome (CFS) are important and common conditions. They are considered together here because they are commonly comorbid and because of their similarities—they are long-term conditions with a relatively poor prognosis; central nervous system mechanisms and deconditioning play an important role in aetiology; graded exercise and psychological treatments have an important role in management; and comorbid mental disorders are common and have an adverse impact on important outcomes, including disability and chronicity. The prevalence of FM is rising, while that of CFS is declining. There is increased acceptance of the pivotal role of central nervous system factors in FM, while in CFS, the positions of different aetiological ‘movements’ appear bitterly entrenched. The main focus of this chapter is on FM and, in particular, key aspects of aetiology and treatment, especially those relating to the central nervous system.

Management of insomnia and circadian rhythm sleep–wake disorders

Insomnia disorder and circadian rhythm sleep–wake disorders (CRSWDs) are prevalent and impairing sleep disorders and often co-present with psychiatric disorder. Insomnia is characterized by difficulty with initiation and/or maintenance of sleep, driven primarily by cognitive behavioural processes. CRSWDs manifest because of alterations to the endogenous circadian clock (intrinsic) or as a consequence of environmental circumstances (extrinsic). This chapter reviews evidence-based treatments for the management of insomnia and intrinsic CRSWDs (delayed sleep–wake phase disorder, advanced sleep–wake phase disorder, non-24-hour sleep–wake disorder, irregular sleep–wake rhythm disorder). The chapter covers cognitive behavioural therapies, sleep-promoting hypnotics, phototherapy, and exogenous melatonin administration. The chapter also highlight gaps in the existing clinical science and reflects on emergent therapeutic approaches.

Imaging of feeding and eating disorders

The conceptual framework regarding the aetiology of eating disorders (EDs) has changed dramatically in recent decades. Cutting-edge neuroimaging techniques have led to advancements in understanding the underlying neurobiology of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Techniques such as magnetic resonance imaging (MRI), positron emission tomography (PET), and diffusion tensor imaging (DTI) allow the opportunity to examine not only structural, but also functional, abnormalities that contribute to extreme eating behaviours characteristic of these life-threatening disorders. Furthermore, research using imaging paradigms suggests that variations in neurobiology are associated with traits that persist after recovery. This chapter will provide insights regarding neural pathways involved in the processing of appetite, reward, mood, body perception, and cognitive inhibition as they pertain to EDs. Findings relevant to feeding disorders will also be discussed. Conclusions will include considerations of treatment applications and directions for future research.

The eating disorders

This chapter describes the three main eating disorders (anorexia nervosa, bulimia nervosa, and binge eating disorder), together with other similar related states. It explains how they are classified and describes their clinical features, development, and course. It is noted that the eating disorders have many features in common and that people move between them over time. These two observations support adopting a transdiagnostic perspective on these conditions.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is a common and unusually severe mental illness, characterized by distressing or impairing preoccupations with non-existent or slight defects in one’s physical appearance, as well as compulsive behaviours, that aim to examine, improve, hide, or obtain reassurance about the perceived defects. BDD is associated with poor quality of life and marked functional impairment, as well as high rates of suicidal ideation and behaviours. Although BDD is often under-recognized in clinical settings, both pharmacotherapy and psychosocial interventions are effective at reducing BDD symptoms and distress. This chapter presents information on the phenomenology, clinical characteristics, diagnosis, epidemiology, pathogenesis, course, and treatment of BDD.

Treatment of anxiety disorders

The personal and societal burden associated with anxiety disorders is considerable, but many individuals who might benefit from treatment are not recognized. Recognition relies on awareness of psychological and physical symptoms common to all anxiety disorders, and accurate diagnosis on identifying specific features of particular disorders. The need for treatment is determined by the severity and persistence of symptoms, the impact of symptoms on everyday life, the presence of coexisting depressive symptoms, and other features such as response to previous treatment approaches. Patient characteristics and patient and doctor preferences influence the choice of treatment. There is much overlap between anxiety disorders in evidence-based and effective therapies (such as the prescription of a selective serotonin reuptake inhibitor or a course of individual cognitive behavioural therapy), but there are also important differences, so it helps to be familiar with the characteristic features and evidence base for each condition.

The primary prevention of anxiety disorders

This chapter describes the nature of primary prevention of anxiety and reports on evidence for its effectiveness. The chapter first defines prevention before reporting results of a systematic review of randomized controlled trials designed to prevent anxiety. A review of existing trials and associated effect sizes suggests that prevention programmes can be effective in preventing anxiety disorder incidence and symptoms in multiple settings (schools, workplaces, community) across the lifespan. The median effect size at post-test across all studies was 0.21, and 0.25 specifically for cognitive behavioural prevention programmes. Key elements common to prevention programmes are then discussed, including a consideration of programme content and personnel delivering the intervention. Key implementation barriers are raised, together with suggestions for how these might be overcome in order to scale up and offer prevention at a population level. The chapter concludes with a consideration of the impact these programmes could have on anxiety disorder incidence.