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The diagnosis of dementia poses several challenges, as a consequence of which the condition has been widely reported to be underdiagnosed in the general population. Currently, there is no single diagnostic test for dementia and the clinical judgement of primary care physicians is therefore a key determinant in identifying which patients are referred to specialist services for further assessment. This month's Cochrane Corner review found that the clinical judgement of general practitioners is more specific (58–99%) than sensitive (34–91%) in diagnosing dementia, although the data were limited by small sample size and significant heterogeneity. This commentary provides a critical appraisal of this systematic review and attempts to extrapolate conclusions relevant to current clinical practice, including potential areas of further research, to facilitate appropriate and timely referral of patients with suspected dementia to specialist services.
Diagnostic systems are not conducive to compassionate health-bringing psychiatric treatment. The systems were built around the fallacy that the politics of biomedicine could be reliably applied to the emergent properties of human psychological suffering and enable diagnosis-specific treatment packages. The resulting industrialised medicine, which reified people, failed to facilitate the compassion needed for healing. This article outlines an approach to psychiatric practice that involves understanding children's suffering and vulnerabilities in terms of their attachment strategies and adaptation to their context and takes a mindful approach to developing compassionate collaborative treatment goals (intelligent kindness). A shift towards mindful psychiatric medicine would encourage politicians to serve the people by addressing the contexts associated with human suffering and what makes people vulnerable, especially social inequalities. Healthy societies in which the psychiatric dis-ease of the population is adequately addressed will not be built with limited biomedical understanding of dis-ease.
The Expression of the Emotions in Man and Animals has been considered Charles Darwin's forgotten masterpiece and is his only book on psychology. It is also the first ever systematic application of Darwinian theory to the expression of emotions and has been considered by some to be the foundational text of evolutionary psychology. This article explores some key concepts in the book and gives reasons why both psychiatry and psychology can benefit greatly from becoming better acquainted with this work.
Stengel, Cook and Kreeger's Attempted Suicide is the most sustained early attempt to draw out the social setting of an attempt at suicide. It is part of a real flourishing of social psychiatry in the UK and reinforces a productive model for collaboration between research psychiatrists and psychiatric social workers in the 1950s and 1960s. The sheer amount of work required for a robust social setting, charting the social repercussions for an attempt at suicide, is laid bare in this text.
Multiaxial classification system development (organising important and relevant clinical factors under multiple headings or ‘axes’) has a long history stretching back to the 1940s. The World Health Organization supported the development of a multiaxial system of classification for children from the 1960s and in the 1990s produced a comprehensive multiaxial system which could be used with ICD-10. Using the multiaxial approach provides for an atheoretical framework that can integrate factors from within the child and the environmental influences on the child. This article presents a variety of ways in which the ICD-10 multiaxial framework can be extended from its classic usage to provide clinicians with valuable tools to assist in a biopsychosocial clinical assessment. Using the multiaxial system in an extended format allows a more comprehensive diagnosis and planning of treatments and is helpful in the training and teaching of juniors. It is also useful in evaluating responses to medication when it is combined with a chronological analysis and can provide other useful ways of integrating information relevant to understanding clinical cases.
Patients view their negative emotions as troublesome and they expect psychiatrists to deal with them, often wanting them taken away. We present a neuropsychoanalytical understanding of the essential biological function of emotion and how it influences behaviour. Through a vignette, we demonstrate how this understanding can contribute to the psychiatrist's management of the clinical encounter, in particular regarding the patient's expectations about their emotions and the pressures placed on the clinician.
The COVID-19 pandemic significantly increased the challenges faced by families affected by dementia, leading to an immediate increase in both the number of calls received by Dementia UK's Admiral Nurse Dementia Helpline and the levels of distress and complexity of the calls. Consequently, Admiral nurses experienced feelings of helplessness, echoed in the experiences of other health professionals. One of the approaches that enabled Admiral nurses to cope during this time was ‘hope’, and this article explores the use of hope-based approaches as tools for working therapeutically with families during the pandemic. Although written from the perspective of Admiral nurses, the approaches described are transferable to others working across health and social care. The article provides an overview of one of the main models of hope in the healthcare literature, Snyder's hope model, and explores the literature on hope more widely. Fictitious case vignettes, drawn from clinical practice during the pandemic, are used to illustrate how hope-based approaches can be applied to practice.
Eye movement desensitisation and reprocessing (EMDR) is a psychological therapy that addresses trauma, stress and emotional distress. It has been successfully used in the management of various psychiatric disorders. This article shows that it may also be safely used to manage the psychological distress arising from a variety of physical health conditions and in so doing, reduce the illness burden from conditions such as various cancers, traumatic childbirth, tokophobia, pre-eclampsia, myocardial infarction, haemodialysis in end-stage renal disease, and acute postoperative pain. It can be a stand-alone treatment for hyperemesis gravidarum and tinnitus. The article examines the rationale and evidence for its use in these conditions and suggests areas where more research is needed. Adding EMDR therapy to the range of available interventions in general hospitals has the potential to improve the health and well-being of patients in these settings.
In A Plea for the Insane (1918), Lionel Weatherly outlined the inadequacies of the Lunacy Act 1890 and of asylum care in England and Wales, and proposed solutions and ways to bring about improvements. It took courage to persist, but Weatherly was undeterred by controversy or criticism. This article reflects on his book and its context and timing at the end of the First World War, and considers whether we may be inspired to confront current healthcare crises with the same sort of passion and fervour as he did.
There is a widening gap between the medical model of dementia and critical sociological perspectives of the condition. Given the relative failure of reductionism in dementia and its rising prevalence, consideration of the utility of these critical viewpoints is warranted. This article considers how these ideas, which challenge some prevailing assumptions about dementia, can be meaningfully applied in conjunction, rather than in competition, with conventional clinical ideas. To illustrate this, current perspectives on selfhood, biopolitics, citizenship and post-humanism are discussed. This article may also help to articulate sociologically oriented approaches already used by some clinicians and legitimise the time and attention needed to explore and deliver these. We support the view that dementia is an episteme in the making and that different traditions and dispositions can fruitfully collide to enliven interdisciplinary conversations about dementia and dementia care.
This issue of BJPsych Advances includes an article on the use of hypnotherapy in psychiatric practice. The article contains a number of errors and misconceptions regarding the characteristics and practice of hypnosis that we address in this commentary.
This is a commentary on two articles on assessing mental capacity in everyday practice and in the case of the suicidal patient. It explores some of the conceptual problems with capacity, including the lack of a ‘right’ answer and the value-laden nature of capacity assessments in suicidal patients. In England and Wales, in addition to the Mental Capacity Act 2005 clinicians must also consider their duty of care as part of the European Convention on Human Rights as enacted in the Human Rights Act 1998.
This is the first of two articles reviewing consent in those under the age of 18 (also referred to as ‘minors’ in UK law). This can be a complex issue in clinical practice because the law endows competent/capacitated minors with the absolute right to accept treatment, but a limited right to refuse. This first article summarises recent cases of refusal of treatment in minors. It uses them to ask two central questions: how do we, as clinicians, think about autonomous self-determination in minors and to what extent does the rights agenda support minors’ autonomous self-determination? Autonomy as one of the principles of biomedical ethics is explored. How the minors’ rights agenda supports the development of autonomy is considered. The amount of weight given in the domestic courts to the rights of minors with reference to the Human Rights Act 1998 and the United Nations Convention on the Rights of the Child is described. These considerations demonstrate the way that the courts are giving the views of the minor greater weight in decision-making in keeping with age and maturity. This article introduces the second article, which comprehensively reviews decision-making in minors, explores competence and capacity in minors and examines the differential treatment of acceptance and refusal.
This is the second of a pair of articles reviewing the topic of consent in minors. Both articles have a particular emphasis, drawing on theory and case law, on the differential treatment of acceptance and refusal in minors. This article considers the concept of capacity in young people (aged 16 and over) and competence in children (under the age of 16) by reviewing underpinning statute and case law with particular reference to England and Wales. This provides a platform for consideration of the reach of capacity in minors with regard to acceptance and refusal of treatment. In doing so the article explores the key, but still elusive, ingredient of maturity, which has significance to the process. Fictitious vignettes allow consideration of the application of the concepts of maturity and autonomy in clinical practice. The article also considers the potential for the UK's Parliament to make changes to current statute regarding consent in minors.
Advances in data science and machine learning have allowed for the analysis of increasingly complex and large data-sets. Digital devices are a source of such data, given their ability to collect information on users continuously and irrespective of location. Digital phenotyping aims to use these data to build a comprehensive picture of an individual's behaviour. Psychiatry is well-positioned to make use of this, since digital behaviour may be reflective of mental state. This article provides an overview of the field of digital phenotyping as it stands currently, on the verge of large-scale studies which may pave the way for clinical implementation in psychiatry.
Psychiatry in Dissent: Controversial Issues in Thought and Practice was published in 1976. In the book, Irish psychiatrist Anthony Clare (1942–2007) both defended and critiqued contemporary psychiatry. He demystified the field, analysed its problems and argued that psychiatry, for all its flaws, offered a reasoned and reasonable path forward. His arguments remain fiercely relevant today, sometimes eerily so.
The emergence of the COVID-19 pandemic has had a substantial negative psychosocial impact due to both the outbreak and the global response to it. As we know from previous health crises, front-line workers are among the risk groups for developing serious mental health problems. As a result of the continuous exposure to highly stressful circumstances, directly in their jobs and indirectly through media consumption and related societal pressures, healthcare professionals are at increased risk for distress, compassion fatigue, burnout and emotional disorders. Recent studies have been revealing specific stressors faced by healthcare workers during the COVID-19 outbreak, such as limited resources, work overload, fear of infecting significant others and isolation/loneliness. However, research has shown heterogeneity in adaptation to adversities, with many individuals being able to bounce back. Based on this growing evidence, this article provides a clinical working framework to empower healthcare professionals, by critically discussing resilience-promoting strategies along the intra- and interpersonal dimensions of control, coherence and connectedness.
Neurosurgery for mental disorder is performed in the UK for treatment-refractory obsessive–compulsive disorder and depression. In this commentary, the procedures used are considered alongside other surgical interventions for psychiatric conditions. Given the evidence for efficacy, this commentary agrees with Whitehead & Barrera's assessment that such procedures be considered more widely in treatment-refractory illness and concurs that the advent of minimally invasive radiosurgery is an exciting prospect for patients who have not responded to other treatments.
This article aims to provide psychiatrists with an overview of early release of serving prisoners and parole, using the example of the Parole Board for England and Wales. The centrality of risk assessment and management and its clinical implications for release are reviewed. Offenders who come before a parole board and require a psychiatrist to be a member of the panel and who need evidence from psychiatrists on their disorder are often characterised by the complexity of their mental disorder. Offenders with complex mental disorder have difficulty assessing effective treatment and aftercare pathways, which can result in not being released. Offenders remitted back to prison following hospital transfer for treatment experience particular problems in being released. Three roles for psychiatrists in parole hearings are identified and guidance for effective participation in hearings is discussed. Commissioning implications of the difficulty assessing the need for community aftercare are noted.