Psychiatric services

Chapter 21 is concerned with the provision of psychiatric care for populations. It deals mainly with the needs of and provisions for people aged 18–65 years (‘adults of working age’). It covers the history of psychiatric services, the components of a mental health service, services for psychiatric disorder in primary care, specialist services for acute psychiatric disorder, psychiatric services that provide long-term care, services for people with particular needs, difficulties with community care, and international service principles.

Psychological treatments

Chapter 20 is concerned with various kinds of counselling, psychotherapy, behavioural and cognitive therapies, and some related techniques. It addresses that this chapter should be read in conjunction with the general advice about treatment in the chapters on physical treatment and on services, that this chapter contains advice on the general value of various treatments. Advice about the value of these treatments for specific disorders is given in the chapters concerned with the relevant disorders, that psychological treatments are often combined with medication, and appropriate ways of doing this are considered in the chapters concerned with the relevant disorders, that because many different techniques of treatment are considered here, none can be described in detail, and suggestions for further reading are given in several places in the chapter, and lastly, that although outline descriptions of technique are given in several places, supervised experience is essential before any of these treatments can be used with patients.

Reactions to stressful experiences

Chapter 8 begins with a description of the various components of the response to stressful events, including coping strategies and mechanisms of defence. The classification of reactions to stressful experience is discussed next. The various syndromes are then described, including acute stress reactions, post-traumatic stress disorder, special forms of response to severe stress, and adjustment disorders. The chapter ends with an account of special forms of adjustment reaction, including adjustment to bereavement (grief) and to terminal illness, and the problems of adults who experienced sexual abuse in childhood.

Forensic psychiatry

Chapter 24 is concerned with other aspects of psychiatry and the law covered by the term forensic psychiatry, which is used in two ways: narrowly, it is applied to the branch of psychiatry that deals with the assessment and treatment of mentally abnormal offenders; and broadly, the term is applied to all legal aspects of psychiatry, including the civil law and laws regulating psychiatric practice.

Psychiatry and medicine

Chapter 15 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. It covers mind-body dualism, epidemiology and presentation in medical settings, comorbidity, management of psychiatric disorders in the medically ill, unexplained somatic symptoms, somatoform and dissociative disorders, psychiatric services in medical settings, psychiatric aspects of medical procedures and conditions, and psychiatric aspects of obstetrics and gynaecology.

Schizophrenia

Chapter 11 discusses how, of all the major psychiatric syndromes, schizophrenia is the most difficult to define and describe. This partly reflects the fact that, over the past 100 years, widely divergent concepts have been held in different countries and by different psychiatrists. Although there is now a greater consensus, substantial uncertainties remain. Indeed, schizophrenia remains the best example of the fundamental issues with which psychiatry continues to grapple—concepts of disease, classification, and aetiology. Having noted the complexities, we start with an introduction to acute schizophrenia and chronic schizophrenia. The reader should bear in mind that these will be idealized descriptions and comparisons, but it is useful to oversimplify at first before introducing the controversial issues.

Mood disorders

Chapter 10 discusses mood disorders, including clinical features, transcultural features, classification and differential diagnosis, epidemiology and aetiology, course and prognosis, acute treatment of depression and mania, longer-term treatment strategies, assessment and management of depressive disorders, assessment of mania, and management of manic patients.

Aetiology

Psychiatrists are concerned with aetiology in two ways. First, in everyday clinical work they try to discover the causes of the mental disorders presented by individual patients. Secondly, in seeking a wider understanding of psychiatry they are interested in aetiological evidence obtained from clinical studies, community surveys, or laboratory investigations. Correspondingly, the first part of chapter 5 deals with some general issues relating to aetiology in the assessment of the individual patient, while the second part deals with the various scientific disciplines that have been applied to the study of aetiology.

Psychiatry of the elderly

When considering psychiatric disorder in the elderly, the clinician must be able to collect and integrate information from a variety of sources, and produce a management plan which takes account of physical and social needs, as well as psychological ones. This plan is likely to involve the cooperation of several professionals. It is in this clinical complexity that much of the challenge and fascination of old age psychiatry lies. Chapter 18 deals with the psychiatry of old age, with two important exceptions, both of which were covered in Chapter 13: delirium, and the clinical features, aetiology, and investigation of dementia.

The misuse of alcohol and drugs

The phrases substance use disorder (DSM-IV) or disorders due to psychoactive drug use (ICD-10) are used to refer to conditions arising from the misuse of alcohol, psychoactive drugs, or other chemicals such as volatile substances. In this chapter, problems related to alcohol will be discussed first under the general heading of alcohol use disorders. Problems related to drugs and other chemicals will then be discussed under the general heading of other substance use disorders.