26.1 General introduction 6445 Michael Sharpe

26.1 General introduction 6445 Michael Sharpe

ESSENTIALS All physicians experience situations in which they need the know- ledge, skills, and attitudes commonly thought of as belonging to psychiatry. This section of the book aims to help physicians to ac- quire these. It includes:  (1) guidance on how to assess medical patients for psychiatric illness; (2)  information about psychiatric presentations and the differential diagnoses most relevant to general medical practice; (3) brief reviews of the psychiatric disorders most commonly seen in general medical practice and the practical man- agement of these; (4) guidance on the use of psychotropic drugs and psychological treatments when given as part of general medical care; (5) evidence-​based strategies for helping patients who are smoking, using alcohol excessively, or who are overweight. Introduction Physicians face diagnostic and management problems every day for which even a detailed knowledge of physical disease biology does not alone provide an answer. In such cases, the knowledge, skills, and attitudes, usually thought of as ‘psychiatric’ can be helpful. Examples include the patient with whom doctors find it hard to form a working relationship, patients who are emotionally distressed, and patients who present with physical symptoms that are not explained by identifiable disease. It is unfortunate that psychiatry and medicine have become so divorced from one another, and that the subject matter of psych- iatry has consequently become inaccessible to the physician. The historical separation of psychiatry from the rest of medicine still shapes our thinking and practice, and even the organization of our health services. Indeed, in recent decades, trends in both medicine and psychiatry have tended to widen this historical split: modern medicine has focused increasingly on understanding the molecular biology of disease and less on the whole patient, while psychiatry has focused increasingly on the psychoses and less on the more common psychological problems seen in medical patients. More recently, however, increasing awareness of the fact that medical and psychiatric illnesses often coexist in the same patient has led to a strong trend towards the reintegration of psychiatry into general medical practice. Psychiatric knowledge that is relevant to general medical prac- tice includes useful (if imperfect) systems of classifying illnesses (see next) and evidence for pharmacological and psychological treatments. Relevant psychiatric skills include the ability to manage the consultation effectively, to assess the patient’s mental state as well as their physical state, and to find out about the patient’s own understanding of their illness. The attitude of non-​ judgemental acceptance of socially deviant behaviour, essential to the care of severely mentally ill people, may also be helpful to the physician. It is no secret that some physicians can be dismissive towards patients whom they perceive as ‘psychiatric’. A  doctor who is comfortable with and tolerant of patients who have medic- ally unexplained symptoms, illogical fears, or difficult behaviour is likely to be both better able to help these patients and to enjoy their medical practice. Although most physicians do a great deal of what may be referred to as ‘psychiatry’ themselves, specialist psychiatric help is not infre- quently required. Unfortunately, appropriate and useful psychiatric and psychological services are frequently hard to access. This reflects ad- ministrative and geographical separation of services and often a lack of understanding of the pressures of acute medical care by those working in mental health services. Fortunately, in recent years there has been a slow but steady growth in general hospital-​based psychiatry and psych- ology services that are specifically dedicated to helping physicians meet the needs of their patients. These services offer improved access and greater acceptability to patients than general psychiatry services, and also are better equipped to manage the problems that are common in medical patients. These services are called liaison psychiatry (linking psychiatry and medicine), psychological medicine (specializing in psy- chological aspects of medicine), and in parts of Europe, psychosomatic medicine (medicine that links mind and body). The chapters The sections that follow aim to provide a practical, and hope- fully accessible, summary of those aspects of the assessment and 26.1 General introduction Michael Sharpe

section 26  Psychiatric and drug-related disorders 6446 management of patients conventionally termed ‘psychiatric’, but which are in fact central to the practice of all of medicine. They include: • Guidance on how to do an efficient psychiatric assessment of a medical patient. • Information about those psychiatric presentations most relevant to general medical practice, including confusion, low mood, med- ically unexplained symptoms, and self-​harm, and the differential diagnosis for each. • Brief reviews of the psychiatric diagnoses most commonly encoun- tered in general medical practice including organic mental dis- orders (delirium and dementia), emotional disorders (depression and anxiety), severe reactions to stressors, somatic symptom dis- order, personality disorders, and eating disorders, as well as more basic coverage of the less commonly encountered but important psychiatric diagnoses of bipolar disorder and schizophrenia. • Guidance on the use of psychotropic drugs and psychological treatments when given as part of general medical care. • Useful advice on how to help patients with the common and clinically important problems of alcohol and substance misuse, obesity, and smoking. While some readers might regard this section of the book as merely an unnecessary ‘add on’ to the core contents of a medical textbook, of questionable relevance to the practising physician, I hope most will find it helpful in understanding and meeting their patients’ needs. A note on the classification of psychiatric diagnoses The most widely used classification of psychiatric diagnoses in the United Kingdom and United States is the American Psychiatric Association Diagnostic and Statistical Manual, known as DSM. Currently in its fifth edition, it is known as DSM-​5. The other classification frequently used for coding diagnoses is the section in the World health Organization’s International Classification of Diseases known as ICD. Currently in its tenth edi- tion, it is referred to as ICD-​10. FURTHER READING American Psychiatric Association (2013). Diagnostic and statis- tical manual of mental disorders, 5th edition (DSM-​5). American Psychiatric Press, Washington D.C. Geddes J, Andreason N, Goodwin G (eds) (2017). The new Oxford text- book of psychiatry. Oxford University Press, Oxford. Levenson JL (ed) (2018). Textbook of psychosomatic medicine and consultation-liaison psychiatry, 3rd edition. American Psychiatric Association, Washington D.C. Lloyd G, Guthrie E (eds) (2011). Handbook of liaison psychiatry. Cambridge University Press, Cambridge UK. Sharpe M (2010). Psychiatry in general medical settings. In: Johnstone EC, et  al. (eds), Companion to psychiatric studies, 8th edition. Churchill Livingstone. Edinburgh.