Psychiatry 3rd edition pdf free download cutler

By commenting in comment box its easier for us to reupload Books. Thanks for your cooperation. Please enter your comment! Please enter your name here. You have entered an incorrect email address! Leave this field empty. If you still feel your copyrights have been violated, then you may contact us immediately: Contact us: admin cmecde.

Insight Patient appears to have an excellent understanding of having a mental illness that has profoundly affected his life:Ive lost so much. Spontaneously explains that beliefs about people wanting to hurt him and the conviction that he was Jesus Christ were crazy.

Judgment Patient appears to be cooperative with his treatment. He feels that his attitude is better now in that he understands the need to take his medication. He realizes that he came very close to dying and is relieved that he did notdie. Urine toxicology screen at the time of admission was negative for recreational drugs including marijuana, cocaine, and opiates.

Brain MRI shows moderate cortical atrophy, including enlarged ventricles; no focal findings. CASE SUMMARY The patient is a year-old man with a 5-year history of intermittent psychotic and mood symptoms who was admitted 1 week ago after making a serious suicide attempt in response to command auditory hallucinations.

His medical condition is now stable. His mental status examination is notable for blunted affect. The patient no longer appears to be psychotic, and he denies current suicidal ideation. His mood symptoms both depression and mania suggest the possibility of schizoaffective disorder, most recent episode depressed, although overall it is not clear how predominant those symptoms are in relation to his psychotic symptoms see Chapter4, Schizophrenia and Other Psychotic Disorders.

Amood disorder with psychotic features seems unlikely as he has been psychotic without mood symptoms e. Asubstance-related psychotic disorder seems unlikely given his recent abstinence confirmed by his negative toxicology screen on admission.

There is no evidence of another medical cause for his symptoms, and his MRI scan is consistent with chronic schizophrenia see Chapter4, Schizophrenia and Other Psychotic Disorders. Diagnosis: Chronic schizophrenia versus schizoaffective disorder; status post suicide attempt, medical sequelae resolved. Biological Factors A genetic predisposition seems likely, given his family history. Drug use may have played a role in precipitating his first psychotic episode.

Medication nonadherence may be contributing to his recurring symptoms. Psychological Factors The patient was raised by a loving caregiver, but his childhood was nonetheless marked by deprivation and trauma, as his father was absent and his mother was probably emotionally unavailable to him given her own psychiatric and substance abuse problems, culminating in her unexpected and traumatic death during his adolescence. Recent stressors include the anniversary of his mothers death, and his growing realization that he may never be able towork.

Social Factors The patient has been struggling with acceptance of his chronic mental illness, which has isolated him to some extent from his family and friends, in part as a direct result of the illness, but also probably due to social stigma. He may not require a long hospitalization if he remains asymptomatic, and the psychosocial aspects of the treatment plan outlined below may be conducted on an outpatient basis.

The role of the hospital staff would be to locate appropriate programs and facilitate the patients initial referral and connection tothem. The decision may be informed by further clarifying his degree of medication nonadherence, since his psychotic symptoms are now resolved on the same medications that he was taking prior to admission. Along-acting injectable antipsychotic may help address the nonadherenceissue. Psychological Treatment Group psychotherapy with other patients with chronic mental illness may be helpful, if he can feel comfortable in a group setting, in order to provide ongoing psychoeducation and support in his struggle to accept the realistic limitations of his likely chronic psychiatric disorder see Psychosocial Treatment in Chapter 4, Schizophrenia and Other Psychotic Disorders.

Supportive psychotherapy on an individual basis may help him to develop better coping skills and, in a carefully modulated manner, better awareness of and control over the continued impact of his childhood marked by deprivation andloss. Social Treatment Given his growing demoralization in the face of his apparent inability to work, participation in a day program may be useful to provide a more structured and.

Aday program would also help to mitigate his social isolation. The patient currently appears to have good insight and judgment, but his repeated episodes of medication nonadherence are of concern, as are his strong family history and recurrent psychotic episodes.

The fact that he acted in response to command auditory hallucinations to make a nearly fatal suicide attempt is extremely concerning. The presence of mood symptoms and the possibility of a diagnosis of schizoaffective disorder are better prognostic indicators, as is the consistent presence in his life of his supportive grandmother her age and health should be inquired about, as he will be at high risk for decompensation when her health deteriorates.

LaboratoryTests Blood and urine tests are frequently crucial adjunctive data to a thorough history in rul- ing out other medical conditions as possible causes of psychiatric symptoms as well as in identifying unrelated medical illnesses requiring treatment. In addition to the standard chemistry and hematological panels, toxicology screening should always be considered to rule out substance-induced disorders see Chapter7, Substance-Related and Addictive Disorders. Specialized blood tests and other modalities such as computerized tomogra- phy CT scanning, magnetic resonance imaging MRI , and electroencephalography EEG can be used to screen for possible causes of delirium e.

Aneuropsychological battery of tests can sometimes be useful. All testing should be done with an eye toward balanc- ing costs both economic costs and health risks to the patient with possible benefits. This judgment is based on a realistic estimate of the probability of a particular condition given its prevalence and the patients presentation see chapters on individual disorders, particularly Chapter5, Neurocognitive Disorders and Mental Disorders Due to Another Medical Condition, for specific indications.

Case Summary While the history presents the facts in such a way that readers can make their own judg- ments as to the validity of the interviewers conclusions, the case summary begins the process of integration. The case summary remains descriptive, but it is more tightly focused and analytical than the patient-focused perspective of the history and the purely observational tone of the mental status examination.

As the example in Box 1. Yet it is an important step toward identifying those findings in a particular patient that are similar to those found in other patients i. It is also a step toward completing other aspects of the overall assessment that can be at least as important as the diagnosis:Is the patient a danger to himself or herself, or to others?

Will the patient be adherent to medication and other treatment recommenda- tions? Thus, the case summary may include statements about the patients current level of functioning and behavior patterns, as well as assessments of particular symptom patterns and risks.

For example, the physician might conclude that a patient is psychotic i. The term psychotic is at a level of overall assessment that does not belong in the mental status examination itself but should be included in the case summary as the physician begins to reach conclusions.

Similarly, while the patients thoughts, fantasies, and plans regarding suicide are recorded in the mental status examination, the physi- cians impression of the patients impulse control and suicide risk should be included, when relevant, in the case summary. Differential Diagnosis The diagnosis summarizes patterns of data, predicts the course of an illness and the recov- ery from it, and suggests treatment options.

In the systematic process of case formulation, the diagnosis is a separate step that is reached only after the patients psychopathology has been summarized descriptively. Following this sequence keeps physicians disci- plined and helps them consider all appropriate diagnoses systematically. This sequence does not mean that physicians are not thinking about diagnoses until this point. On the contrary, diagnostic possibilities are being entertained, patterns are being sought, and hypotheses considered and discarded all the while the physician is gathering data and making observations.

By the time the physician begins to create the written record, the most likely diagnoses should have been identified. The entire case write-up is organized with those diagnoses in mind. However, following the formal sequence of steps i. Identifying specific diagnoses should be relatively simple after the psychopathology has been carefully described.

The first question to answer is which general category of psychopathology does the patients symptoms fit into, based on the history of the present illness and the mental status examination. These categories include the mood, psychotic, cognitive, anxiety, and personality disorders.

This is where knowledge of characteristic diag- nostic and prevalence patterns, including gender and age differences, is most crucial. For example, a year-old with no prior psychiatric history presented with audi- tory hallucinations and grandiose delusions, which had been occurring for six months.

Because of the frequent onset of schizophrenia during adolescence, this disorder quickly became the most likely diagnosis, based on this brief piece of history. Substance-induced psychotic episode and bipolar disorder would be two other possibilities in the differ- ential diagnosis. Ayear-old woman with the same presentation is much more likely to be suffering from a mood disorder with a manic episode or mixed features, while a year-old woman would be given a diagnosis of psychiatric disorder due to a another medical condition until this was proved otherwise.

Acloser look at more details about the patients condition will either confirm the initial diagnosis or suggest other, less obvious diagnoses. The degree of certainty regarding the diagnosis depends in part on the amount of detailed historical information available. Abrief initial evaluation interview will probably generate a long list of possible differential diagnoses, whereas a formulation composed at the end of a lengthy hospital stay should present a fairly definite diagnostic impression.

Predisposing and Precipitating Factors The formulation is not complete even after a diagnosis has been reached. The diagnosis reflects only those signs and symptoms that the patient shares with other patients who have the same disorder. Assigning a diagnostic label identifies common features but tends to blur the more subtle, and not so subtle, distinctions among individual patients with the same diagnosis. While this diagnostic labeling is crucial for purposes of communicating with others involved with the patients care and for beginning to establish a prognosis and develop a treatment plan, it is not sufficient for describing an individual person who is suf- fering from an illness.

The biopsychosocial approach describes the patients strengths and vulnerabilities and helps to convey the patients uniqueness. Vulnerabilities can also be labeled as possible predisposing or precipitating factors. In recent years, the bio- psychosocial approach has been expanded to include a cultural formulation, which con- siders the patients symptoms, stressors, supports, vulnerability, and resilience in relation to his or her cultural reference group.

The case formulation in Box 1. Immediate and long-term goals and concomitant recom- mendations for treatment should be delineated. The patients goals must be given prime importance as the treatment plan is being developed.

The recommendations should include not only the ideal treatments but also those that are feasible given the patients resources. Frequently, an initial step in the treatment plan will be obtaining additional information, such as history from family members and records of prior treatment. The biopsychosocial perspective is useful in treatment planning because it focuses on all aspects of the patients problems and their solutions.

This prediction is based on the physicians specific knowledge of the individual patient and gen- eral knowledge of diseases e. In other words, given the diagnosis, as well as the patients strengths and vulnerabilities, to what extent will he or she recover and perhaps even achieve better personal adjustment?

The sample case formulation in Box 1. DeGowins Diagnostic Examination, 9th ed. Practice Guideline for Psychiatric Evaluation of Adults, 2nd ed. Principles of the Psychiatric Evaluation. Philadelphia: J. Perry, S. Cooper, and R. The psychodynamic formulation:its purpose, structure, and clinical application. American Journal of Psychiatry , Shea, S. Psychiatric Interviewing: The Art of Understanding. Philadelphia: W. T he psychiatric inter view is the physicians most important tool for arriving at a diagnostic and prognostic assessment as well as formulating a treat- ment plan.

It can be thought of as a clinical procedure, deployed for both diagnostic and therapeutic purposes. When the interview is conducted in a supportive and empathic manner, the very act of the physicians seeking information from the patient should alleviate the patients suffering.

Just as mastery of a procedure for the surgeon requires years of study, repetition, supervised practice, and thoughtful review, it can take years to acquire proficiency and a sense of confidence as a psychiatric interviewer. Nonetheless, even a novice can learn to conduct competent, thorough, and therapeutic evaluations. Both types of interviews include the patients subjective account of symptoms and the physicians more objective assessment of the patients thoughts, feelings, appearance, and behavior.

The physician begins both types of interviews by considering the patients chief complaint, that is, what caused the patient to seek help at that point in time. In both types the patient is asked about the present illness and the past history. The psychiatric interview includes a survey of the major realms of psychopathology, which is analogous to the review of sys- tems in other medical evaluations. In addition, the psychiatric interviewer is interested not only in the patients illness and the ways that the patient experiences and copes with it but also with his or her social, academic, and vocational functioning in general, past and present.

Within the conceptual framework of the medical model, psychiatric symptoms are seen as direct manifestations of an illness, just as chest pain is seen as a possible symp- tom of coronary artery disease. The interviewer notes the presence or absence of symp- toms of pertinent illnesses or syndromes, tracks the course of symptoms, and looks for factors that exacerbate or alleviate them, including previous treatment.

Panic disorder, obsessive-compulsive disorder, and major depression lend themselves particularly well to the medicalmodel. While adhering to the basic medical model, the psychiatric interview has four addi- tional essential and distinguishing features: a psychological perspective, empathic.

Begin with open-ended questions. Follow up with focused questions. Avoid technicalterms. Make use of silence. Provide periodic summaries.

Ask for clarification. Attend to emotional responses. Empathize without offering false reassurance. Psychological Perspective To do justice to the complexity of psychiatric illnesses and patients, the physician must employ working models of the mind, in addition to neurobiological models of brain dys- function. The psychodynamic model is a psychological perspective that views unconscious thoughts and feelings as powerful motivators and inhibitors of behavior.

Symptoms are understood not simply as manifestations of brain chemistry but also as reflections of under- lying psychological processes, including psychologically determined solutions to problems and conflicts that the patient may not be consciously aware of.

From the standpoint of this perspective, the patients recurring patterns of behavior in significant interpersonal rela- tionships, past and present, are especially relevant. They represent potential clues to how the patient will experience and relate to the interviewer and to subsequent caretakers. The patients internal psychological conflicts, management of strong affect, and capacity for gratification in love and work are also of primary interest see sample interview in Box2.

Other psychological, behavioral, and social scientific theories are widely employed by contemporary psychiatrists as well. In addition to the psychodynamic perspective, cog- nitive, behavioral, and interpersonal theory can be relevant for the assessment and treat- ment of patients with specific psychiatric disorders. Each theoretical perspective opens up ways of listening to patients, making sense of clinical encounters, and structuring treatments. Theoretical perspectives, or models of the mind, are not mutually exclusive; the psychiatric interviewer views them as complementary and variably useful, depending on the patient, the psychopathology, and the situation.

Empathic Listening Because psychiatric problems are primarily experienced in the mind, the patients subjec- tive experience is of paramount importance. Empathic listening involves actively trying to see the world through the patients eyes.

Empathy requires imagination. Imagining a paranoid patients sense of danger and isolation, for example, or an anxious patients sense of imminent catastrophe, helps the physician capture the inner world of the patient.

She has been in the hospital for 5days. The female physician interviewer just rotated onto the service and is meeting the patient for the firsttime. Interviewer: Can you tell me about the circumstances that led to your hospitalization?

Patient: Im really not in the mood. They told me this morning that you would be my doctor. Icould tell Iwasnt going to feel comfortable talking to you. You look younger than I am!

The interviewer did not know quite how to respond. The patient got a bit angrier and looked the physician up and down. The interviewer was tense but remained composed. And Iget this feeling that youre too confident, cold and clinical. Very straight. Too straight and middle class. You look perfect, with your outfit and yourhair. I: Isee. Well, where do we go from here? Youve given up before youve even started. P: Oh, Ihave started. Listen, Im sorry, but Ireally just cant see you treating me.

How do Iget assigned another doctor? I: Idont know, Ithink youd have to talk to the director of theunit. P: Maybe Ican be assigned to the other doctor. She looks like she speaks Spanish.

I: Would you be more comfortable speaking Spanish? P: [The patient snapped angrily. I: OK, Im sorry. Let me talk to my director, and Ill get back toyou.

In this vignette, the interviewer is faced with a difficult and serious challenge. The patient is overtly hostile and contemptuous, making hurtful and personal attacks, rejecting wholesale the physician as a person as well as anything that she might have to offer. Such situations can be decentering and demoralizing; they can stir up strong feelings toward the patient that impact the present moment as well as the course of ensuing treatment.

Conceptualizing what has gone wrong can inform an attempt to salvage the interview and the treatment. Because the patient has refused to engage in the interview, the physician has correctly chosen to focus on the impasse, although the intervention might have gotten more traction if she had referred specifically to their relationship changes italicized : Youve given up on me before weve even started.

When the patient redoubled her rejection, the physician remained composed and professional, assessing whether the patient was concerned about a language barrier. The patient snapped back in a dramatically disrespectful manner. Understandably, the interviewer felt taken aback by the attack, and helpless to connect with the patient. The physicians sense of defeat is in part realistic:there can be no productive interview until the patients anger is addressed.

The patients behavior and affect may. The evaluation that is necessary to make that determination cannot proceed because the patients response to the physician has ground the interview to a halt. How can the physician understand and manage this stalemate?

First, the physician must register that the patient has very concretely transferred onto the physician a whole set of assumptions, beliefs, and motivations that belong to the patients internal world. The patient is displaying an intense emotional and psychological response to the physician, despite not knowing her.

Keeping in mind that this response reflects the patients psychology, and is virtually unrelated to the physician, can help the interviewer to feel less personally affected, rejected, offended, or emotionally reactive. Separating the patients fantasies from reality will help the interviewer to gain some distance from and perspective on the patients distortions so that they can be named, thought about, discussed, and understood. The interviewer may then be able to call to mind what little she knows about the patientfor example, that her mother has died and her most recent physician has rotated off service.

This information could lead the interviewer to hypothesize that the patient might be feeling abandoned, helpless, and angry, as well as terrified about getting close to and losing another caretaking figure, with all the pain that can entail. This understanding can help the interviewer begin to find seeds of empathy for the patient. Maintaining an attitude of unwavering respect and engaged curiosity, and taking a nondefensive and nonjudgmental approach, the interviewer could then make any one of the interventions listed below that felt most comfortable.

Interventions such as these will elaborate more of the patients inner world and put into words impulses, feelings, and fantasies that the patient is otherwise enacting, thus paving the way for the beginning of a collaborative interview and doctorpatient relationship. I can assure you Im not perfect, but tell me more about why youre so sure Icant help you based only on my appearance. You obviously doubt that someone like me can helpyou.

Youre having a very strong reaction to me, and Id like to understand it more. What else have you noticed about me to convince you Im of nouse? It sounds like Ireally seem quite young and incompetent to you right now. And very straight. What kinds of experiences have you had with people who are similar to the way you seeme? How do you see me as straight? How do you see yourself as a lot to handle? What were the first things you noticed, when you knew you werent going to feel comfortable talking to me?

It sounds like an awful feeling for you tohave. Its as if, in your mind, theres an image of me as a detached and uppity doctor, very different from you, almost too different to understand and relate to you in a helpfulway. Patients who feel that the interviewer wants to and can understand their perspective are far more likely to cooperate meaningfully with the interview.

The physicians communica- tion of understanding often helps the patient feel less confused, helpless, or alone. This, in turn, may help patients feel better about themselves, crucially mitigating feelings of guilt, humiliation, or shame. The patients experience of feeling understood, together with the phy- sicians emotional experience of coming to empathic understanding and making empathic contact, constitutes the bedrock of the therapeutic alliance.

In the process of sharing their suffering with the physician, patients may experience a measure of relief. The interviewer who encounters the patient once only can still effect a truly therapeutic interaction.

Listening to the patients verbal communication involves hearing more than the explicit meaning of the words. The physician tries to register the music of the language. All elements of language, including figures of speech and tonal modulation, convey emo- tions and contribute to the depth and meaning of verbal communication.

Likewise, the interviewer should be attuned to other implicit aspects of the patients speechsuch as the ease or difficulty of following the story; the order in which it is told; omissions, hesita- tions, contradictions; as well as the congruence or lack thereof between what is being said and how the patient says it. The physician also listens to the patients nonverbal com- munication, or body language, which includes facial expressions, gestures, and posture.

Physician Emotional Responses In addition to verbal and nonverbal communication, the psychiatric interviewer tunes in to a third channel of communication:his or her own emotional responses to the patient. The physician who is authentically involved in the interviewlistening, imagining, trying to empathizeis bound to have emotional responses in the process. Indeed, the absence of any emotional response in the physician, or a general emotional blandness coming through on this channel, is itself a significant deviation from the expectable and, as such, should prompt reflection and further investigation.

There are numerous potential barriers to the physicians ability to make an emotional connection with a patient. Barriers may stem from the patient, the interviewer, or their mutual interaction. Before arriving at any conclusions, the interviewer needs to subject his or her own emotional responses to critical inquiry:Am Ihaving a personal, idiosyncratic response to this patient?

Am Ifeeling something that the patient is having trouble acknowledging? Is it possible that the patient is inducing these feelings in me, and if so, how and why might the patient communicate with me in this way? Thinking about psychiatry 2. Psychiatric assessment 3. Symptoms of psychiatric illness 4. Evidence-based psychiatry 5. Organic illness 6. Schizophrenia and related psychoses 7. Depressive illness 8. Bipolar illness 9.

Anxiety and stress-related disorders Eating and impulse-control disorders Sleep disorders Sexual disorders Personality disorders Old age psychiatry He trained in Psychiatry in South East Scotland.

Together with a group of friends and colleagues he wrote the first edition of the Oxford Handbook of Psychiatry. For the clinicians, it is a good read especially for junior doctors who are on call and need a practical book to refer to.

This book is well-written and well-organised with a good readable style. BMA Book Awards Highly Commended. Click it to start your free download now.

Download Link.