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Psychological therapies 12
Tom Murphy Jon Patrick Susan Llewelyn
Introduction for a Scientific Psychology’ (Freud 1895) should continue.
This led to the formation of different groups within the psycho-
A brief history of the psychotherapies analytic institutes and allowed for new work and ideas to
emerge, most notably from psychoanalysts such as Wilfred
Psychotherapy, if thought of as the means by which emotional Bion, Donald Winnicott and others within the object relations
distress is ameliorated by communication, has probably school. In other countries the different schools were not always
existed for centuries, not only amongst humans. John Bowlby, so well accommodated as in Britain. Jacques Lacan and his
father of attachment theory, made particular reference to this followers in France split off from the mainstream, while in
ethological perspective when considering the behaviour of the USA the development of Kleinian object relations was not
chimpanzees and by extension to humans (Bowlby 1969). well received and the Institutes there remained ‘classically’
Unsurprisingly, perhaps, it required human beings’ greater Freudian in orientation until relatively recently, Otto Kernberg
capacity for language to make these forms of relatedness more being at the forefront of this change. Also in the USA, Heinz
sophisticated and formalised. Kohut developed psychoanalytic theories in a direction he
called ‘self-psychology’. In the UK John Bowlby continued to
Arguably, this process took a leap forward with the work of develop attachment theory and this, together with his film
Sigmund Freud after he witnessed Jean-Martin Charcot’s work with the Robertsons (Robertson 1953) was influential in
demonstrations of hypnosis at the Salpˆetri`ere Institute in Paris British Government policy with regard to child care, leading
in the late 19th century. Freud posited that there had to be to foster care replacing orphanages (see Bowlby 1969).
some element mediating between mind and body to explain
the effects that he saw at the Institute, effects which closely At the same time as Freud was constructing his theoretical
mirrored the symptoms presented by patients diagnosed with models in Paris and Vienna, Ivan Pavlov formulated the cor-
hysteria. This element was conceptualised and labelled by nerstone of his work on behaviourism at the University of
Freud as the unconscious (Freud 1900), a theory which ran Leningrad. His famous experiments with dogs and salivation
counter to the more commonly held belief, at that time, in demonstrated that environmental stimuli could be paired with
Cartesian duality which regarded mind and body as separate. physiological reflexes by a process called classical conditioning
(Pavlov 1927). These ideas were then extended to cover
Freud developed these theories, or metapsychology, through- more complicated behaviours some of which were voluntary.
out the first two decades of the 20th century looking at areas This work was described by Thorndike in his Law of Effects
surrounding symptom formation, defence mechanisms, ‘trans- (Hernstein 1970) and further delineated by Skinner into what
ference’ and infantile sexuality using an investigative empirical is known as operant conditioning. Their studies have had appli-
approach. He was accompanied, at times briefly, on this journey cations for the practice of psychotherapy especially in the
by notable followers including Carl Jung, Sandor Ferenczi and fields of behavioural therapy and cognitive-behavioural therapy
others. Latterly his work was extended by his daughter Anna (CBT) – see below.
Freud and by Melanie Klein. Following Freud’s death in 1939
a number of so-called ‘controversial discussions’ were held The relatively simplistic approach of the early behaviourists
between 1941 and 1946 (King & Steiner 1991) in London was extended as developments in the theory of cognitivism
wherein those allied with classical Freudian theory, led by occurred throughout the 20th century. Albert Ellis, having
Anna Freud, debated with those analysts in step with the become disillusioned with his practice as a psychoanalyst,
‘object relations’ thinking of Melanie Klein on how his ‘Project began looking at and challenging his patients’ behaviours
and thoughts that appeared to be self-defeating (Ellis 1958).
ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00012-7
Companion to Psychiatric Studies
This new therapy, rational emotive behavioural therapy, was to The unconscious and Freudian metapsychology
be the first of the CBTs, a family of therapies further devel-
oped by Aaron T. Beck. Beck, also a psychoanalyst, expanded Despite the varying schools of psychodynamic thinking, all
Ellis’ work and brought new concepts to bear on the problem would adopt a stance that we all have an unconscious life that
of psychological ill health (Beck 1976). In turn these have determines much of what we think and feel about ourselves
been added to, to create newer therapies, some of which are and the world around us. Initially, Freud felt the unconscious
hybrids, e.g. cognitive-analytical therapy, and others focussing was expressed through basic drives or impulses, primarily
on alternative areas, e.g. mindfulness in dialectical-behavioural sexual in origin and fuelled by sexual energy – libido. When
therapy. the outcome (or derivative) of a drive is unacceptable to the
conscious mind, this leads to its being repressed out of aware-
All the above therapies are deemed to be psychological ness, with a consequent symptom being formed which in some
in nature and hence are given the title ‘psychotherapies’ or way symbolically expresses the repressed impulse. This
‘psychological therapies’, terms which are synonymous but stemmed from his work with patients suffering from hysteria,
both continue to be used as they very loosely reflect something anxiety-hysteria (phobic anxiety) or obsessional neurosis in
of the different professional identities of the professionals. Victorian-era Austria (Freud 1895). All of these ideas were
What distinguishes them from other therapies? The answer, developed on the basis of clinical observation of a relatively
as alluded to in the opening statement of this chapter, is that small number of cases. While this work has been highly influ-
they all primarily utilise communication to facilitate a reduc- ential and has to some extent been modified by later concepts
tion in emotional distress rather than medication or other the core ideas are those developed on the basis of clinical
physical methods. Nevertheless, most psychotherapists would observation about 100 years ago. There is no empirical evi-
view medication as a valuable addition to their patients’ man- dence for Freud’s theories and they do not lend themselves
agement and hence frequently use these approaches in combi- to development of testable hypotheses. Thus, influential as
nation. In the sections below, the different modalities’ these ideas and concepts have been the situation is that you
different approaches to treatment are outlined. It is important accept them or you do not. The central themes and concepts
first to note that there are a number of factors that they all are outlined below.
have in common (Frank 1973, 1982), notably:
Freud began to realise that this metapsychological view was
1. non-judgemental and empathetic attitude of the therapist; overly simplistic and he developed the topographical model
2. a trusting and confiding relationship; of the mind (Freud 1923) linked to earlier work in The Inter-
3. structure and boundaries which formalise the setting; pretation of Dreams (Freud 1900). He postulated that people’s
4. installation of hope; minds were divided into three distinct entities. The uncon-
5. a theoretical rationale for treatment; and scious contains those drives and wishes that are repressed,
6. a recognisable treatment process. while the preconscious acts an ‘anteroom’ between the uncon-
scious and the third, conscious, part of the mind. Within the
A further useful concept to be considered at the outset is that preconscious, a process of censorship is continuously underway
of psychological mindedness, which can be described as an indi- to prevent unacceptable thoughts and feelings from entering
vidual being able to reflect on their actions, feeling, motives, awareness. It is of note that the ‘pleasure principle’ wherein
relationships, etc., and also consider their meanings. An indi- pleasure is sought and unpleasure, e.g. anxiety, is avoided,
vidual displays this attribute to the extent that he or she is the dominant force in this model. When this comes into
demonstrates both interest in and ability for such reflection conflict with the demands and constraints of reality (known
across both affective and intellectual dimensions (Hall 1992). as the ‘reality principle’) then symptoms are formed as
It is also an essential characteristic for psychotherapists symbolic compromises.
themselves.
Freud’s observations in his clinical practice also led him to
Psychodynamic psychotherapy see the mind as comprised of internal conflicts between the
different internal forces (hence ‘psychodynamics’). He devised
Psychoanalytic theory the Structural Model of the Mind (Freud 1923) to describe
this, which is structured in three parts. It is possible to
Psychoanalytic theory, which is the basis for all psychody- view the structural model as also indicating a slight shift in
namic work, is founded on the idea that our thoughts, feelings orientation, marking increased recognition of the importance
and actions are all expressions not only of conscious rational of relationships. This should not be overemphasised as Freud’s
factors but also of hidden unconscious processes or impulses. work had always recognised this aspect in, for example, the
These expressions may take the form of symptoms which, concept of transference. Nevertheless, it is possible that this
although seemingly maladaptive or unpleasant, in fact provide model had a facilitating effect on later theorists leading them
primary gain i.e. relief from the anxiety aroused due to having to develop relationship factors still further.
the unacceptable impulse. Secondary gain may also be
provided, as for example when the sick-role is adopted which The structural model did not supercede the topographical
affords patients the chance to reduce their responsibilities and model as the two models described different conceptual
gain the right to be looked after. frameworks and run in parallel with one another. In the struc-
tural model the id is totally unconscious, wishes to follow
the pleasure principle and is governed by Primary Process
Thinking – see Table 12.1. The ego is the conscious part of
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Psychological therapies CHAPTER 12
Table 12.1 Primary and secondary process thinking competitor for her affections, namely the father – i.e. the
Oedipus complex. Castration anxiety refers to how threatened
Primary process thinking Secondary process thinking the child feels at the fantasy of father’s revenge by castration.
For the female child the situation is broadly similar with the
Absence of logic in construction, Logical sequencing: operates with parental roles reversed. Additionally the female child desires
e.g. by employing displacement reality orientation and reality father’s potency resulting in penis envy. Both the fear of attack
(one apparently insignificant idea is testing (executive function) i.e. and potential loss of the love of the same sex parent result in
invested with all the intensity reasoning, attention, concentration the gradual giving up of the fantasy of possessing the opposite
attributed to another) and sex parent. These conflicts lead to the formation of the super-
condensation (a single image Contradictions evident ego as an internalised threatening (morally critical) parent. The
represents several different and Negation present child then moves on to the ‘latency phase’ in which psycho-
separate associations) sexual development is ‘dormant’ and involves consolidating
the resolution of the Oedipus conflict and developing social
No contradictions relationships outside of the family, until puberty ushers in
the the ‘genital phase’ in which the individual seeks a partner
No negation of their own to replace the Oedipal loss (Fancher 1973).
Not bound by concept of time Time-bound
No distinction of fact from fantasy Fact differentiated from fantasy The development of psychoanalysis
Adapted from Laplanche & Pontalis 1988. Clinically, Freud initially worked using abreaction under
hypnosis (with the patient lying on a couch) to uncover uncon-
the mind that deals with day-to-day existence and actions. scious thoughts and feelings (Breuer & Freud 1895) and
It functions by secondary process thinking which ‘modifies release the strong affects associated with (usually early child-
and performs a regulatory function for primary process think- hood) trauma – the ‘cathartic method’. His patients frequently
ing’‘ – see Table 12.1. The superego straddles both conscious described traumatic incidents in childhood of ‘seduction’ by
and unconscious portions of the mind and represents the inter- adults, and they appeared to recover when the strong feelings
nalisation of moral and social conventions initially as a result of linked to the details of the traumatic events were uncovered –
the Oedipus complex (see below). Freud felt that the ego has an understanding that he called the ‘seduction theory’. The
to serve ‘three harsh masters’ (Freud 1923) namely the id, difficulty in hypnotising some patients led to his abandoning
superego and reality. If it cannot manage this equilibrium, then this method in favour of simply compelling them to remember
symptoms develop. the childhood events (the ‘pressure technique’). This was even-
tally abandoned in favour of requiring his patients to ‘free
Psychosexual development in Freudian theory associate’ (see ‘Free association and dream analysis’) whilst
lying on the couch. However, Freud became increasingly
In Freudian theory the super-ego is a consequence of the uneasy about accepting patients’ accounts of childhood sexual
working through of the Oedipus complex (Freud 1905) which trauma as he found the sheer numbers involved to lack credi-
is a part of the child’s psychosexual development. According bility. From his own thinking and self-analysis, it occurred
to Freud’s theory the infant initially exists in a state of to him that his patients’ accounts might come from their
complete self-absorption, primary narcissism, concerned only own sexual fantasies about the adults with whom they were
with basic needs (food, warmth, etc.) and pleasurable sensory in contact. This led him to reformulate his understanding of
stimulation which it receives from any source (‘polymorphous the clinical problems as the theory of infantile sexuality and
perversity’). With development, the infant’s sexual instinct psychosexual development (see ‘Psychosexual development
becomes more structured and focussed around ‘erotogenic in Freudian theory’)(see also Fancher 1973).
zones’. As feeding is a major activity the infant begins to focus
its receiving of pleasure and excitement through suckling and Debate persists as to whether Freud had in fact uncovered
the mouth – the ‘oral phase’. The next, ‘anal’ phase comes widespread child sexual abuse within Viennese society which
between 1 and 2 years of age as the infant gains a greater he then lacked the courage to expose, or whether he genuinely
awareness of others’ requirements of it and the battle for con- believed that the problem was mainly fantasy – he never main-
trol that this implies – this conflict is played out over who con- tained that childhood sexual abuse did not exist. In recent
trols the child’s expulsion of faeces and associated excitement years this question has received considerable publicity, and
from the stimulation of anal mucous membrane during defeca- few, if any, psychoanalysts would now think that a report of
tion. Further physical and psychological development leads to sexual abuse in childhood could be assumed to be fantasy
interest in, and stimulation of the genitals, through infantile (Masson 1984).
masturbation, in the ‘phallic phase’ at about 4 years. This psy-
chological development also brings greater awareness of the With the shift of focus to the patient’s fantasy life, the new
triangular relationship of child, mother and father, which theory proved fruitful for the continued development of
greatly increases rivalry between the child and particularly psychoanalysis, leading to the conceptualising of dreams, the
the opposite sex parent. In normal development, the male unconscious (see ‘The unconscious and Freudian metapsychol-
child wishes to possess the mother and eliminate the ogy’), defence mechanisms (see Table 12.2A) and transference
(see ‘Transference, counter-transference and repetition-
compulsion’). Analyses remained short in the early 1900s but
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Companion to Psychiatric Studies
Table 12.2A Immature defence mechanisms – primitive mentally divide up a caregiver, i.e. an external object, into
either all-good or all-bad internalised (introjected) mental
Defence mechanism Process representations (internal objects) as they are unable to perform
the more sophisticated task of accepting that a real person is a
Splitting A person will divide off parts of themselves that mixture of both. This phase of development is known as the
they find bad, e.g. their anger, and deny that paranoid-schizoid position (Klein 1946) and is characterised
they are like this. Alternatively this may happen by the child using primitive defence mechanisms such as
in an interpersonal arena when a person will feel splitting, projection and projective identification to ensure that
that others are ‘all good’ or ‘all bad’. Both of it can continue to feel itself to be good and not bad – i.e. ideal
these preserve an equilibrium for the patient in (Tables 12.2A–C). Over time and with what Winnicott
that they will not have to tolerate conflicting called good-enough mothering (see ‘Notable other theorists –
feelings about themselves or someone else D.W. Winnicott and C.G. Jung’), which allows the child to
internalise a secure good-enough view of themselves, the child
Projection This is when split-off parts of the self (as above) would move from the paranoid-schizoid position to the depres-
are then attributed to other people. The other sive position in which there is a loss of idealisation (hence
person may or may not be affected by it ‘depressive’) and an acknowledgement of ambivalence, seeing
that both oneself and real people are each a mixture of good
Projective identification Here the split-off and projected element is taken and bad. These two positions are never fully resolved and adult
in by the other person who is then affected and life is a mixture of functioning in both of these, i.e. reverting
may react. Neither will be conscious of what has to the paranoid-schizoid position under stress, and returning
happened, e.g if the patient views a staff to the reality-orientated depressive position when more secure
member as rigid (projection), that staff member and supported. The relationships with others are mediated
may become frustrated and angry with the through the internal objects by means of introjection and
patient as a reaction against what has been projection.
projected into him. Neither will be aware of their
role in what has happened Klein and her followers’ work has been further developed
by later clinical theorists (Segal 1986). For example,
Idealisation/denigration Produced by splitting and projection of idealised
and denigrated aspects; these 2 processes mean
that the patient idealises and denigrates different Table 12.2B Immature defence mechanisms – neurotic
figures in their life ensuring that the patient does
not have to tolerate ambivalence
Dissociation In this case the patient will absent themselves Defence mechanism Process
from reality so as not to be in contact with
painful feelings or thoughts which it brings Repression The person will unconsciously put out of their
conscious mind any idea or impulse that runs
Acting out Rather than remember and tolerate difficult past contrary to their preferred conscious view. In
experiences, the person will enact them, e.g. if contrast, ‘supression’ is when the person
criticised they might react to this directly by consciously decides not to think about
cutting themselves because they reacted self- something
punitively as a child to parental criticism. The
term does not apply when a person is e.g. Identification A person will take on the characteristics,
merely enacting angry feelings. psychic or otherwise, of another, e.g. in
‘identification with the aggressor’ a person
within a few years were longer and more formalised due to may take on the aggressive/abusive aspects of
working with more entrenched clinical problems which someone (parent) rather than feel the victim of
required a more complete resolution of the transference rela- aggression or abuse themselves. Following
tionship, rather then just alleviation of isolated symptoms. bereavement the person may unconsciously
mimic the symptoms that led to the death
The extensions of Freud’s works – object
relations, self-psychology and beyond Rationalisation A person will justify their thoughts, feelings
and actions using what may appear to them to
When Sigmund Freud died in 1939, his successors further be a logically plausible, but actually unrelated,
extended his ideas in a number of different directions, primar- reason
ily within the object relations and ego psychology schools.
Undoing/magical thinking Seen e.g. in OCD; this is when a person will
The object relations theorists, who were based primarily in feel that doing a certain thing will ‘magically’
the UK and were led by Melanie Klein, focussed more on negate an unacceptable thought or wish
a relational perspective seeing the development of object
relations as having an impact from earlier infancy. Klein, from Displacement This is when an unacceptable impulse, thought
her work in child psychoanalysis, observed that infants or feeling is expressed towards someone or
something unconsciously more acceptable,
e.g. aggressively loading your dishwasher
instead of shouting at your partner
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Psychological therapies CHAPTER 12
Table 12.2C Mature defence mechanisms – higher them and psychologically hold them, i.e. provide an
environment where they are thought about and responded
Defence mechanism Process to. This has applicability to adult clinical practice insofar as
practitioners should be able to perform a similar function
Sublimation Consciously unacceptable wishes are diverted by, for example, protecting the analytical space by keeping
into constructive and socially acceptable outlets, boundaries clear, being mentally available for the patient,
Humour e.g. a violent person becoming a doctor. This including being aware that their own problems may affect
Altruism should be distinguished from other mechanisms, how they are responding and so try not to impose values
Compensation particularly ‘displacement’ in which the person is and prejudices, and attend to the physical environment –
enacting the impulse the consulting room temperature and extraneous noise, etc.
This potentially provides a space (‘facilitating
Here a person will make a difficult situation a environment’) for patients to grow and develop (‘the
source of humour rather than something that maturational process’) (Winnicott 1965).
might distress them consciously • Good-enough mothering – This concept is linked with the
idea of the holding environment. Winnicott felt that
‘Selflessly’ acting for others and thereby avoiding mothering (parenting) that was too responsive or
the difficulty of attending to one’s own needs unresponsive could lead to future emotional difficulties.
If mother is too responsive the infant will not develop
Excelling in one area rather than attending to a their own abilities to manage in the world and if too
domain in which one inwardly feels one is inferior unresponsive they will be overly anxious and find life
unmanageable as a result (Winnicott 1971).
McDougal (1986) likened humans’ minds to a theatre made • Counter-transference hate – Patients, like infants, can evoke
up of introjected objects and the relationships between them. strong feelings in their carers. One such feeling is hatred.
Thus, a patient who has experienced, and hence introjected, Winnicott normalised this by making this link and stating
their father as cruel and rejecting may later interpret, by pro- that it is important to acknowledge this to prevent both
jecting onto others the image of the internalised cruel father, burn-out and acting out feelings towards patients (and
that real people are acting cruelly. Furthermore, the patient children) (Winnicott 1949).
may also adopt the other side of the relationship and act in a
cruel and rejecting manner themselves. Hence they can con- Carl Gustav Jung was initially chosen by Freud as his successor
tinue to act in different roles in the play that they know so but over time it became clearer that their theoretical orienta-
well from growing up. These relationships form the basis of tions were becoming incompatible. He has provided a number
the transference (see ‘Transference, counter-transference and of ideas that remain of interest today.
repetition-compulsion’).
• The collective unconscious and archetypes – This describes
The self-psychologists led by Kohut (Kohut & Wolf 1978) Jung’s belief in shared universal symbols that are held in
have seen the mind’s primary internal object relationship as everyone’s minds, appearing in the form of archetypes
determined by the child’s interaction with mother in three found in our dreams, mythology and fairytales, etc. which
ways, namely empathy, mirroring and idealisation. The combi- then structure how we think and feel about the world
nation of these interactions provides the child with an interna- (Jung 1959).
lised self-object which, if there has been a failure of any/all of
these communications, can lead to psychopathology. • Extraversion-introversion – Jung believed that people can be
located on a spectrum of extra- to introversion. Those
More latterly attempts have been made to devise simplified closer to the former pole are sensation-seeking, sociable and
applications of these theories incorporating other ideas, such more confident than those at the latter (Jung 1921). This
as attachment theory (Bowlby & Ainsworth 1991), to provide way of understanding personality has been built on by later
a broader based service to many more patients outside of theorists and led to the development of the Myers–Briggs
psychoanalysis, e.g. mentalisation-based treatment, which is a type indicator (McCaulley et al 1998) which is still used by
current approach to providing a treatment service to patients private and public sector organisations today.
with borderline personality disorder (Bateman & Fonagy
2008a,b). Important psychodynamic concepts
Notable other theorists – D.W. Winnicott and Transference, counter-transference and
C.G. Jung repetition-compulsion
Donald Winnicott’s clinical background as a paediatrician and Transference is the process whereby an individual brings
later a practising psychoanalyst led him to create a number thoughts, ideas, affects which are held about early figures in
of theoretical constructs from his observations within both of their life, most notably parents, to bear on (i.e. literally transfer
these fields, and in addition to psychoanalytic writings, he also to) their current relationships, and experience them similarly.
wrote directly for health professionals more generally. These reactions are most seen clearly within psychoanalytic
therapy because the therapist provides a blank screen for the
• The holding environment – Winnicott proposed that for patient to interact with and deploy their pathology onto.
children to grow up physically as well as psychologically
healthy, their parents must be able to both physically hold
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In therapy, transference allows the therapist to see first-hand be too anxiety inducing and hence unsustainable for the
how the patient interprets the world around them. patient, as well as on a more pragmatic level, being too burden-
some in terms of NHS resources to be used as routine clinical
Correspondingly the counter-transference consists of all the practice. Psychodynamic work, i.e. less frequent sessions held
therapist’s thoughts, ideas and affects about the patient. Some while seated face to face, may be more appropriate with
of these may be due to the therapist’s own upbringing (the respect to these latter factors.
therapist’s ‘transference’), which need to be kept separate
and managed by supervision and the training analysis. Impor- At the outset, session time(s) are negotiated with the
tantly there are also the therapist’s conscious and unconscious patient and then maintained, as far as practically possible, for
responses to the reality of the patient’s presentation including the duration of therapy, which may or may not be time-
the patient’s projections (see Table 12.2A). These responses limited itself. This ensures that there are firm boundaries so
provide vital information about the patient’s functioning as that the patient can feel contained by the process. Firm bound-
well as explain how other people may feel when they are with aries also enable both therapist and patient to see how the
the patient. Counter-transference is therefore partly used to patient reacts to reality, e.g. if a patient is consistently late,
inform interpretations (see ‘Other therapist interventions’). they may be communicating something by acting out. ‘Breaks’
in therapy, e.g. the therapist’s leave, termination of treat-
Transference results in mentally reconfiguring the present as ment and other important events, are foreshadowed by the
if it were the same as the past. It is therefore linked with the individual session boundaries.
idea of repetition-compulsion wherein we are all ‘condemned’
to repeat our early experiences throughout our lives. The therapist adopts a boundaried attitude to themselves
by not providing personal information or acting in a way that
Defence mechanisms would interfere with being a blank screen for the patient’s pro-
jections but crucially this does not preclude the therapist
Defence mechanisms are normal mental functions that aim to maintaining a warm and genuine attitude which is essential
limit emotional distress in our conscious minds. Initially they to maintain the therapeutic relationship (see The relationship
are unsophisticated, or primitive, but with healthy psychologi- and therapeutic alliance).
cal development they become more mature and sophisticated.
The first defence to be described by Freud was repression as The relationship and therapeutic alliance
the process by which ideas unacceptable to our conscious
selves are dynamically pushed back into our unconscious. The relationship between analyst and patient is of paramount
A list, although not exhaustive, of other defences is outlined importance in psychodynamic work, as it is here that the
in Tables 12.2A–C. patient will demonstrate how they interact with the world.
Seeing this in the here-and-now through the transference
Negative therapeutic reaction affords both parties an opportunity to explore how the
patient’s internal world is made manifest and provides a more
The negative therapeutic reaction, first described by Freud in immediate basis for interpretations to be made.
1923 (Freud 1923) can be divided into two distinct parts.
Firstly it is a phenomenological description of when a patient’s A specific component of the patient–therapist relationship
illness becomes worse, or they wish to discontinue therapy, is the therapeutic alliance, comprised of three components:
following what the therapist and/or the patient may have seen
as a helpful intervention. Secondly it is an explanation of when 1. the working alliance – the mutual conscious investment of
improvement in symptoms may evoke guilt in some patients, patient and therapist in the therapy;
particularly those who are masochistic (Sandler et al 1970).
Improvement is therefore avoided as it keeps such patients’ 2. mutual affirmation – similar in nature to Carl Rogers’
psyches in equilibrium. It is important to note that such reac- ‘unconditional positive regard’; and
tions are however not always due to this mechanism (Horney
1936). Other possible causes include a patient feeling envious 3. empathic resonance.
of the therapist’s perceived position or skills, which may also
provoke such reactions. The alliance is of significant import as its quality has been
shown to predict treatment outcome (Horvath & Symonds
Psychodynamic techniques 1991). Traditionally it has been regarded as being distinct from
the transference relationship as it is comprised of the more
Structure and boundaries rational and mature part of the collaborative process between
patient and practitioner (Krupnick 1996), although in reality
Psychodynamic therapies can be practised in a variety of inten- there will be crossover of the two (Greenson 1967).
sities from once-weekly up to five-times weekly contact, with
the patient either seated in a chair or lying on a couch. The Free association and dream analysis
intensity is determined by the patient’s need, as working more
frequently and on the couch (i.e. psychoanalytically), where The only injunction that is made to patients in psychoanalytic
they cannot attune themselves to the therapist’s non-verbal treatment is that they say ‘whatever comes to mind’, i.e. free
cues, can allow the therapy to ‘go deeper’. This may in turn associate (Freud 1895). This enables the therapist to begin to
see where such associations lead the patient. When associa-
tions are blocked this is seen to be due to resistances that are
present because the patient is moving into territory that is
anxiety-provoking. As a corollary to this, the therapist remains
in a state of evenly suspended attention (Freud 1912), in order
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not to be drawn into the patient’s defences, e.g. what the interpersonal component to their difficulties supports referral,
patient consciously wishes to focus on, but instead remains given the relational nature of the therapy itself. As such,
available to what is unconscious. patients with cluster B personality traits/disorders may partic-
ularly find the work of value – specific reference to the
In this context dream analysis allows the patient to reveal a evidence is made in ‘The evidence-base’. There is, however, a
representation of their mind that has not been censored by caveat to this statement insofar as for patients to have this
their preconscious. In this way dreams are, as Freud said kind of therapy a degree of psychological mindedness is advis-
(Freud, 1900) ‘the royal road to the unconscious’. The term able, as if not present, the therapy may seem to the patient to
dream work refers to the dreamer turning the latent content lack relevance. It is also advisable that the patient should be
into manifest content using symbolisation, condensation, able to cope with understanding more about themselves as
etc. – see below. without this the therapy could be destabilising. In this latter
respect the availability of supports in the patient’s family
Dreams and dream work (adapted from Laplanche & or social circle is highly relevant, and on occasion it may be
Pontalis 1988) necessary to agree an ‘emergency plan’ with the patient.
1. Dreams are prompted by experiences during the day which Following from this, there has been some discussion (Silver
make up the day residue, comprised of instinctual wishes 2001) about analytical work with psychotic patients. There is
derived from events (or vice versa) in the day which are no absolute contraindication for this but it would be inadvis-
then gratified in the dream – the purpose of this is to able for inexperienced therapists to attempt this unsupervised,
preserve sleep while impulses continue. due to the force of the transference and the risk of serious
acting out of the transference relationship. Apart from such
2. When working with dreams psychoanalysts will: considerations and the obvious practical difficulties of gaining
cooperation with analytic methods in, for example, manic
(a) note the day residue present; patients, psychoanalysis is not generally recommended in the
(b) consider the meaning of the latent content – the treatment of patients with schizophrenia (see Chapter 15).
underlying unconscious thoughts which lie underneath How else can it help?
the material of the dream;
(c) be mindful of what the patient presents in the manifest Psychodynamic and psychoanalytic concepts are of value
content – i.e. the dream that the patient is able to beyond the consulting room especially when considering diffi-
experience and remember; and culties in relating and communicating in couples, families,
(d) be aware of the secondary revision of the dream’s within and across teams and inside institutions. Realising and
contents – the abridged, consciously acceptable, version understanding that what is being overtly stated is not what is
of the manifest content wherein material has been both actually going on can lead those involved to take actions to
added and subtracted in the retelling of the dream to unstick situations or, alternatively, may allow intractably stuck
the analyst. situations to feel less difficult (Menzies-Lyth 1970).
Other therapist interventions Becoming aware that patients may be unconsciously enact-
ing their internal world dramas with the treating mental health
Some of psychodynamic therapy’s effects are probably due teams and that these teams may be, in turn, responding uncon-
to the underlying attitude of non-judgemental enquiry and sciously to this (due to projective identification), can allow
containment provided by the therapist and their boundaries. positive development to occur in the relationships, in much
Other therapeutic interventions are also utilised including the same way as gaining insight can allow patients in more tra-
clarifying what the patient means, enquiry about the patient’s ditional analytic settings an opportunity to explore and resolve
thoughts and feelings, as well as making interpretations. The their difficulties. Equally the reverse also applies when uncon-
last are when the therapist suggests an explanation for what scious negative team dynamics are being unhelpfully enacted
is happening between them, how this links with the patient’s with patients.
childhood experience and, in its most complete form, how this
situation is mirrored in the patient’s current life, hence leading The importance of supervision
to insight. It is important to stress that interpretations are
hypotheses to further understanding rather than facts for the Given what has been written above about how psychic events
patient to accept. These techniques, in combination with con- and people’s actions unfold unconsciously and interpersonally,
frontation by the therapist concerning what is observed (e.g. it is important to stress the value of supervision. This is when
lateness) and what the patient is avoiding, allow therapeutic patients’ case material as well as the counter-transference of
work to occur. the therapist are brought to an experienced practitioner, in a
spirit of mutual enquiry, to see what might be happening
Practical issues below the surface in therapy. In the way that a father can pro-
vide a third position to look on at the relationship between
Who should be referred for psychodynamic work? mother and baby, which is inevitably and appropriately inter-
twined, the uninvolved supervisor is in a position to stand
Psychodynamic psychotherapy is of value for patients across back from what is happening in an analytical therapy and see
the spectrum of affective, anxiety, and personality disorders; interactions that are not easily seen from close up.
however, a conscious awareness in the patient of a significant
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Controversies Time-limited psychotherapy (TLP)
The theories of psychoanalysis and psychodynamics have In this approach (Mann 1973), contact begins with one or two
consistently aroused controversy since Freud first suggested consultation interviews in order to clarify what the patient is
that young children might have sexual feelings. They continue seeking. This leads to the formulation of a ‘central issue’ which
to arouse debate also due to the lack of empirical proof that is accounts for the patient’s emotional pain, including the main
available for metapsychological theories in general. Perhaps problem brought by the patient, and some statement about
more problematic in today’s market-driven healthcare systems the link to problems earlier in the patient’s life and how they
is psychodynamic therapy’s lack of an evidence base, as viewed have recurrently attempted to adapt to this, but without any
by contemporary health service culture, compounded by its resolution. When putting the formulation to the patient, the
relative expense in terms of training and time. It is not easy emphasis is on making emotional contact, which motivates
in current circumstances to make the case for a form of treat- them to say more and gives an indication that they can make
ment lacking support from empirical evidence, about which use of an exploratory approach. This will also engender a feel-
testable hypotheses cannot be constructed and where much ing of closeness between patient and therapist. One particular
resource is consumed. characteristic of TLP is that therapy is limited to 12 hours,
most commonly a 50–60 minute session once a week for
The short-term, focal and brief 12 weeks. The decision to offer therapy is made by the thera-
pist after the initial exploratory interviews; the date of the
psychotherapies final session is put in the diary at that point and is not altered
by holidays, illness, weather, etc. The conscious intention is to
Brief psychodynamic psychotherapy bring home life’s realities at the outset, in particular to con-
front the sense of timelessness which is a part of neurotic
As the cost of healthcare continues to spiral upward, so does symptomatology, and universal underlying anxiety about sepa-
the concern. At least in the short term, the shorter the length ration – ‘mastery of separation anxiety becomes the model for
of therapy the less it will cost, and the more patients can be the mastery of other neurotic anxieties’. Mann also stresses the
seen for the same money. Caution is required as this policy importance of reinforcing the patient’s responsibility to help
may cost more in the long run if shorter therapies are ineffec- themselves, lowering expectations of an all-powerful therapist,
tive and patients’ clinical conditions become chronic. Never- and of remembering how resourceful patients can actually be
theless, in services with long waiting lists, the promise of when given a modest amount of help.
being able to offer therapy to more people is undoubtedly
attractive. Additionally, from the perspective of research, Mann also describes ‘four basic universal conflict situations’
shorter treatments allow an easier fit with the timescales which seem to emerge in variable degrees in all therapies
involved; hence most psychotherapy research is carried out regardless of the central conflict and which relate to separation
on brief therapy. anxiety (separation–individuation conflict) and a person’s
capacity to bear loss:
Many models of brief psychodynamic psychotherapy have
been developed and a more detailed account can be found in 1. independence vs. dependence;
Ashurst (1991). All have in common a limitation on the
breadth and depth of treatment, with the aim of focussing 2. activity vs. passivity;
on a limited number of the patient’s problems. There is no
expectation that, for example, the patient would regress to 3. adequate self-esteem vs. loss of self-esteem; and
form a transference neurosis as is seen in psychoanalysis.
Nevertheless all hold to the essential concepts developed by 4. unresolved grief.
psychoanalysis – unconscious impulses, fantasy and defence
mechanisms, transference, working through and interpreta- The typical sequence of events in therapy is described by
tion. Often slightly different terminology is used, and selective Mann as follows. In the first few sessions the patient is typi-
attention is paid to what therapist and patient consciously cally relieved to be in therapy, idealises the situation and
regard as most pressing or important. expansively talks about themselves. The therapist consistently
refers back to the central issue in a way which conveys con-
Not all patients will benefit from this short-term treatment fidence that the patient is capable of tackling it. After the
model, and a number of selection criteria are applied, in addi- third or fourth session the patient starts to feel constricted
tion to the criteria for a psychodynamic approach generally. by the therapist’s stance, but usually partly and ambivalently
Patients with psychotic disorders, severe personality disorders, responds to the therapist’s confidence that the issue can be
acute situational crises and behavioural problems without a confronted. Over the next few sessions the patient’s ambiva-
clear interpersonal context (including OCD) would be seen lence about the therapy – whether they will magically be able
as unlikely to benefit (or even might be made worse), as would to sort out all problems – becomes more obvious. In this posi-
patients who are likely to need to see a therapist for longer tion they are confronted by their inability to achieve every-
term support. A requirement for ‘good ego strength’ is gener- thing they had hoped for (as if by magic). As termination
ally explicit or implied, meaning that the patient is able to approaches there will be more direct expression of concern
understand and work with the realities of the situation, includ- by the patient about not achieving ‘the big breakthrough’,
ing being able to manage the brief nature of the therapy. and this will be taken up in detail by the therapist including
discussion of some of the patient’s basic underlying fears and
the problem of thinking about situations in extreme terms,
rather than the more usual ordinary reality. The disappointment
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Psychological therapies CHAPTER 12
with therapy is likely to be expressed by a degree of acting out, which is relieved by (3) defences which keep the impulse
such as coming late to sessions. In the eleventh and twelfth out of awareness. Second is the ‘triangle of person’ in which
sessions there will be indications that the patient is finding alter- a patient’s feelings about (1)the parent (‘p’) are reflected in
natives to therapy in their real life and has moved closer to com- their views of (2) third parties (the other – ‘o’) and their views
ing to terms with (‘mastering’) the ending. There may also be of (3) the therapist (‘T’) in the transference. The therapist
signs that the patient has internalised some aspects of the thera- uses these triangular relationship models to become aware of
pist, such as greater acceptance of emotional reactions and an defended hidden painful feelings, bring them to the patient’s
increased capacity to be reflective. attention and interpret their meaning to the patient in the con-
text of their relationship with their parent and the therapeutic
Psychodynamic interpersonal therapy (PIT) relationship – ‘the T/P link’ above. Malan’s book gives a very
lively account of the use of this model with many clinical
PIT (Guthrie 1999) has been developed and refined over examples (Malan 1979) – see also Ashurst in Holmes (1991)
30 years by Hobson (1985) and was originally called ‘the con- for a more detailed description of this and several other brief
versational model’ of psychotherapy. It has also been used in psychotherapy models, and their use in an NHS psychother-
UK-based psychotherapy research, looking at the effectiveness apy department.
of dynamic approaches (Shapiro & Firth 1987).
Very brief psychotherapy
Lying between psychodynamic psychotherapy and IPT (see
‘Interpersonal psychotherapy (IPT)’) it is a relational therapy The foregoing psychotherapy models all regard brief therapy as
and takes the basic psychodynamic position that many mental between 12 and 26 sessions, or longer in some circumstances.
health problems arise from disturbance in interpersonal There have however been attempts at much shorter therapies,
relationships. These disturbances are the focus of the therapy, motivated by a wish to respond constructively to the problem
rather than the accompanying symptoms (e.g. depression, of NHS waiting lists in psychotherapy departments. Two
eating disorder, etc.), although the model can be tailored models are VBPT (‘very brief psychotherapy’) developed by
towards these. Aveline (2001) in Nottingham and ‘two plus one’ therapy
developed by Barkham et al (1999).
There are seven components to the therapy, many of which
are recognisable as components of other psychotherapies, Interpersonal psychotherapy (IPT)
although with a different emphasis:
IPT has evolved since its development in 1968 as a time-
1. explanatory rationale; limited weekly psychotherapy for the treatment of the ‘ambu-
2. shared understanding (using statements rather than latory non-bipolar, non-psychotic, depressed patient’, in the
light of concerns about high relapse rates in patients treated
questions; a language of mutuality; a negotiating style; by medication alone (Klerman et al, 1984; Klerman &
metaphor; understanding hypotheses); Weissman 1993).
3. staying with feelings (focus on here and now);
4. focus on difficult feelings; IPT makes no assumptions about the causes of depression.
5. gaining insight (linking hypotheses, explanatory However, the model comes from ideas about the importance
hypotheses); of personal relationships in the context and maintenance of
6. sequencing of interventions; and mental disorders, found in the writings of Adolf Meyer (Meyer
7. making changes. 1957) and Harry Stack Sullivan (Sullivan 1953), and also in
the work of John Bowlby (Bowlby 1969) on human bonding
The format allows for brief or longer term therapy, with a con- and attachment theory. The authors also point to the links
tract for the number of sessions agreed at the start. The model between interpersonal/social stress and depression, studies
has also been evaluated successfully for the treatment of on the protective effects of intimacy and social supports
depression and of somatisation in a number of controlled stud- (Brown & Harris 1978).
ies (Guthrie 1999).
In line with this, IPT focuses on four major problem areas
Malan’s model of individual psychotherapy most commonly associated with depression:
David Malan’s work over many years evaluating treatment at 1. grief and loss;
the Tavistock Clinic in London led to the development of a 2. role (frequently marital) disputes;
brief focal psychotherapy model which adhered more closely 3. role transition; and
to the psychoanalytic model than any of the others described 4. interpersonal deficit.
in this chapter (Malan 1979). In his studies of brief psycho-
therapy models he found that interpretations by the therapist In the initial sessions of a 16-session treatment of depression,
of a patient’s hidden feelings in the context of the transference the diagnosis of depression is confirmed by examination; the
relationship with the therapist produced the best outcome. He need for medication is assessed; and the patient is thereby
illustrated this as two related triangles. First is ‘the triangle of given a ‘sick role’. The interpersonal context is reviewed
conflict’ in which the three vertices are: (1) ‘hidden’ (uncon- including significant present and past relationships and the
scious) impulse which causes the person to feel, (2) anxiety nature of the interaction. The four major problem areas and
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Companion to Psychiatric Studies
relationships relevant to the current depression are identified. physical disorders where the cause is established
IPT is explained and a treatment contract agreed. In the inter- and treatment is available but that treatment is not wholly
mediate sessions the relevant major problem area is focussed successful (see Chapter 24).
on, e.g. facilitating a mourning process, sorting through a role
dispute, getting to grips with new roles, or encouraging the for- CBT is normally delivered as a brief intervention and does
mation of new relationships perhaps by reflecting on what can not aim to achieve major personality change, but rather pur-
be learned from the relationship with the therapist. In the ports to help people to cope better by developing more adap-
final sessions the end of treatment is acknowledged and its loss tive ways of living. CBT is also being used as the basis for a
is appropriately grieved together with recognition of the large-scale intervention in the UK for mental health problems
patient’s ability to manage independently. in primary care (Increasing Access to Psycholoical Therapies,
IAPT; Department of Health 2007). Some treatments have
In all of the above the therapist is active and does not inter- been manualised or computerised so that it can be delivered
pret the therapeutic relationship as transference. IPT differs effectively by staff who have received only relatively short per-
from both CBT and psychodynamic psychotherapy by not iods of training (Marks et al 2003). CBT has also been adapted
conceptualising the patient as an individual with unconscious for use in self-help books or DVDs (e.g. Papworth 2006)
impulses or maladaptive negative concepts. Instead IPT views which has further assisted its growth and use for an increasing
the patient entirely in a relationship context and applies itself range of presentations.
explicitly to the task of alleviating and resolving interpersonal
problems. Components of CBT
A significant empirical research basis for IPT has been Behaviourism
growing over the years. Implicit in its development was the
intention that the treatment should be empirically verifiable. CBT consists of two components, which were developed
For example, in one large multi-centred NIMH trial, which sequentially and can still be applied separately as well as in
demonstrated the efficacy of IPT, manuals ensured treatment combination. As noted above, the first approach to develop
fidelity, and only experienced therapists trained in psychody- was behaviour therapy which was based on the assumption
namic psychotherapy and IPT were used (Elkin et al 1989). that all behaviour is learned, including dysfunctional behaviour
and can thus be modified by new learning, or by re-learning old
Since the original model was developed for acute depres- patterns. The underlying models of classical conditioning
sion, the indications have broadened to include other aspects (based on Pavlov’s work) and operant conditioning (based on
of the treatment of depression, e.g. maintenance therapy, Skinner’s work) are applied to clinical problems by manipulat-
conjoint therapy, interpersonal counselling (IPC) (six session ing the reinforcement contingencies of target behaviours, i.e.
counselling for stress), and other patient groups, adolescent by carefully altering the consequences when a patient does
and late-life depression, dysthymia and bulimia. something. For example, a man’s anxiety about spiders is
understood as his failure to learn that spiders are essentially
The behavioural and cognitive harmless, as well as his learning that avoidance of spiders is
rewarding (the relief felt when the spider is successfully
therapies avoided). Treatment therefore consists of gradual exposure
to spiders of increasing size, while carrying out a relaxation
Introduction procedure which is incompatible with anxiety, until the man’s
anxiety is extinguished and avoidance is no longer rewarding.
Cognitive–behavioural therapy (CBT) is an umbrella term This process is known as systematic desensitisation (Wolpe
covering a range of therapeutic approaches whose components 1958).
were originally developed from experimental psychology with
its emphasis on the observable and measurable, and on the In behavioural treatment, the aim is essentially to assess and
importance of empirical evidence. CBT is increasingly being control the antecedents of behaviour, by changing its conse-
seen as the treatment of choice for a wide variety of psycho- quences. An important concept is that of functional analysis,
logical and psychiatric problems (in primary and secondary an assessment process whereby it is possible to understand
care), and has been supported by a range of research trials what purpose is served by a particular behaviour by observing
for a growing number of psychological conditions ranging from what precedes, accompanies and follows it, to establish if
psychosis to anxiety (for a review, see Roth & Fonagay 2004). there are links between these, and hence offering an opportu-
It has also been recommended by NICE for a variety of pre- nity to influence the behaviour. This approach can be used
sentations (see ‘The evidence-base’), and is often promoted very effectively where verbal or cognitive ability is limited,
as being the most clearly evidence-based of the psychothera- for example in encouraging pro-social behaviour by rewarding
pies, if only because more research has been carried out in efforts at communication, with long-stay psychiatric patients
CBT than other therapies. Its use in various conditions and (Hollin & Trower 1986), people with learning disabilities (Ball
the evidence in its support is described in the various disease - et al 2004) or those with dementia (Sturmey 2007). Beha-
specific chapters, e.g. Chapters 15, 16, 17, 18 and 19. Its value vioural principles also underpin many clinical interventions
in helping the distress of carers is noted in Chapter 22 and it is with children (e.g. those with conduct disorder or speech
increasingly used in physical disorders, not only disorders of difficulties, Herbert 1991), as well as some versions of parent
uncertain aetiology such as chronic fatigue but also in serious training, where parents are encouraged to learn to provide
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Psychological therapies CHAPTER 12
rewards such as attention or gold stars for appropriate beha- think about something means that it will happen (thought-
viour while decreasing rewards for inappropriate behaviour action fusion) and that her actions (compulsions) are what
(Webster-Stratton & Herbert 1993). Other useful behavioural has prevented that harm happening in the past (Salkovskis &
interventions include graded exposure (where the prompts to a Kirk 1997; Wells 1997).
particular behaviour are gradually reduced) and cue exposure
(whereby a symbol can be used to perform a discriminative Focus and assumptions of CBT
function to elicit a behaviour); social skills training (a didactic
process whereby individuals are taught, using modelling, more In contrast with a strictly medical model of mental illness,
appropriate social behaviours and repertoires), and time out people with psychological problems are not understood within
(withdrawal of a person from an environment which is reward- either the behavioural or cognitive model as being ‘ill’ or ‘sick’,
ing, with the intention of decreasing the frequency of a but rather as having developed unhelpful patterns of behaving
particular behaviour). and thinking through learning and experiences, which can
therefore best be changed either by altering the environmen-
Behaviour therapy has also been used in the past in treat- tal consequences of that behaviour, or by changing how the
ments aimed at modifying undesirable behaviours, such as person understands themselves and the world around them.
excessive gambling or paedophilia (aversion therapy), where Although it may be dysfunctional, all behaviour can thus be
attempts are made to both construct an unpleasant association understood and potentially be altered, by thinking or acting
between the dysfunctional behaviour and its consequences and differently. It is also assumed that although affect, behaviour,
construct more rewarding consequences for more desirable cognition and bodily symptoms are all linked, changes in affect
behaviour. (emotional distress) and symptoms most easily follow from
changes in cognition and behaviour. Hence, although CBT
Cognition therapists are concerned about a patient’s emotions, they
do not attend directly to these as they are not seen as play-
Growing out of increasing clinical experience and greater ing a central role in maintaining dysfunction. Behavioural
awareness of some of the limitations of behaviourism, together approaches in particular are primarily concerned with attempt-
with the successful development of information processing ing to modify dysfunctional behaviour in the present, and
models within experimental psychology, the second compo- therefore pay most attention to what can be observed and
nent, the cognitive approach to mental distress, has become changed in the present, and in particular, to what a person
increasingly influential. An early theorist, as noted above, was does and what results from this. Because of the emphasis on
Ellis (1962), although probably the cognitive therapy model what can be empirically verified, there is not much concern
most widely used now was proposed by Beck (1976). Origi- for internal thoughts and feelings, which are seen to result
nally applied to depression, Beck’s ideas have now been devel- from or accompany behaviour, not to cause it. In contrast,
oped more widely to cover a range of presentations, including cognitive approaches are primarily concerned with how the
anxiety, health-related problems, post-traumatic stress dis- person makes sense of their experiences and hence cognitive
order (PTSD), health anxiety, eating disorders, psychotic therapists do examine a patient’s thoughts in particular, with
symptoms, personality disorder and children’s emotional diffi- the intention of modifying these, with consequent changes to
culties. Specific models have been evolved for each disorder, the patient’s emotions.
which suggest how particular symptoms, cognitions and beha-
viours are likely to have developed and be maintained in a In practice the two approaches are normally combined
particular presentation. This has implications for what can be (hence CBT), so that the therapist will prompt the patient
addressed therapeutically. to examine and question their unhelpful beliefs (cognitions),
as well as encouraging them to behave differently so that they
The central assumption in the cognitive model is that as can learn new skills or habits (behaviours), which will then
humans, we are constantly processing (perceiving, sorting, promote further revision of their cognitions. For example,
thinking through, selecting) information and that faulty, when treating a depressed woman who believes she is a com-
unhelpful processes also known as cognitive distortions (such plete failure and that she has no friends, the therapist will first
as jumping to conclusions without sufficient evidence, all or try to make explicit her thinking processes via sensitive ques-
nothing, black and white thinking, magnification, personalisa- tioning, followed by a careful examination of whether in fact
tion, catastrophic thinking or prejudice) disrupt our effective the evidence might offer an alterantive interpretation to the
functioning. Disorder is assumed to result not from events woman’s catastrophic conclusion (the cognitive component of
themselves but from how we appraise and hence cope with CBT). The therapist may also suggest that she carries out some
those events. Cognitive models therefore focus on modifying previously avoided behaviours, for example phoning an old
thinking, images, beliefs or cognition, with the assumption that neighbour to suggest meeting (the behavioural component),
emotional changes will follow (Gelder 1997). which together with the cognitive component leads to changes
in her self-perception, behaviour and hence emotional distress.
Assessment in cognitive therapy concerns how dysfunc- Attention is also paid to ‘safety behaviours’ which the patient
tional behaviour and mood disturbances are maintained by may use to avoid exposure to the cognitions or experiences
the person’s cognitions and beliefs, despite the distress these underpinning distress, unwittingly preventing themselves from
may cause. For example, the symptoms of a woman with learning new or more effective behaviours (Salkovskis 1996).
obsessive compulsive disorder are understood to result from For example, a patient with PTSD following a serious road
her faulty assumptions of responsibility for possible harm com-
ing to others, and from her unhelpful beliefs – both that to
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Companion to Psychiatric Studies
traffic accident may avoid cars, or may only drive when heavily Situation
sedated, or when accompanied by his wife, which maintains Thoughts
his difficulty since he never learns that he can in fact cope with
his memories on his own, and move on.
CBT techniques Feelings Behaviour
Central to CBT is the construction with the patient of a perso- Physiology
nalised formulation, based on a generic model for the type of
presentation, which then provides a unique account of the Fig. 12.2 Diagram illustrating the interdependence of factors
development and maintenance of the patient’s particular prob- in CBT.
lem, as well as indicating how change might take place. This
provides a ‘road map’ for conceptualising the problem and occasions. Other techniques used by CBT therapists include
suggests why it has previously been hard for the patient to agenda setting, pleasant activity scheduling (for depression),
resolve this. Normally the therapist will draw up a diagram relaxation training, assertiveness training (a process whereby
with the patient, indicating how cognition, behaviour, physio- patients are taught ways of being able to state their need
logical symptoms and feelings are all linked (Fig. 12.1). clearly without aggression), anger management (whereby
patients are taught how to monitor anger and develop more
The diagram may also suggest predisposing factors (for adaptive behaviours, usually via role play) and relapse preven-
example a family with high levels of anxiety about risk and tion (identification of warning signs of a relapse, and what to
strong beliefs about the importance of responsibility), the pre- do to prevent this). The basic principle throughout is that
cipitating factors (for example an accident or trauma) and the patients learn that their interpretations of reality are crucial
maintaining factors (for example avoidance or beliefs about in determining mood and emotions, rather than reality itself.
not challenging authority). This formulation is constructed
collaboratively with the patient since their understanding of CBT does not seek to explore the past in any detail; never-
the applicability of the model and the possibility of change is theless, the patient’s faulty assumptions and beliefs are
seen as key. assumed to have been learned in childhood and in some
instances may have developed from early traumatic experi-
Following formulation, a variety of strategies can then be ences. These assumptions are based on internalised schemas
used to challenge or modify cognitions, and hence to reduce that then underpin ‘rules for living’, and have significant influ-
distress (Fig. 12.2). These include recording and examining ence because they often lie unexamined. An example is a
thoughts to assess what assumptions are being made, and what young woman who has been abused in childhood, whose inter-
connections exist between cognitions, affect and behaviour. nal schema is ‘I am bad and dirty’ and whose rule for living to
In particular, the therapist will attend to thoughts or beliefs manage this schema is ‘I should do everything right to please
which are made habitually, without conscious thought (known others’. Some CBT therapists aim to identify such schemata
as automatic thoughts) and which trap the patient into existing only in the later stages of therapy, as they are more difficult
unhelpful patterns. This is achieved through a process of to locate and modify; nevertheless, it may be crucial to do so
Socratic questioning in which the patient is led to discover particularly with more complex problems such as eating disor-
for themselves that some of the evidence that they are using ders and personality disorder. Schema focussed therapy is based
is limited or incomplete. Importantly the therapist adopts an on the use of Socratic questioning and discussion, and aims to
empathic stance, often suggesting homework tasks or beha- assist the patient in examining the helpfulness of their assump-
vioural experiments (Bennett-Levy et al 2004) which allow tions, whilst also encouraging the development of more appro-
patients to discover for themselves that some of their assump- priate and coherent behaviours (Young et al 2003). It is crucial
tions are faulty. This process is known as collaborative empiri- that all these treatment approaches are conducted in a way
cism. For example, a chronically shy young woman might be that respects the cultural background of the patient, being
encouraged to test out her prediction that no-one else ever mindful of diversity, and of the different views that a variety
feels anxious before meeting others by conducting a brief of social or ethnic groups may hold about what behaviours
survey amongst her close friends about their anxieties on social are acceptable or desirable.
Defence Therapist Recent developments in CBT
Hidden impulse Anxiety Parent Other Other more recent developments have included CBT for
chronic conditions and coping effectiveness training (Kennedy
Fig. 12.1 Malan’s triangles. (Malan 1995, reproduced by permission et al 2003) in which patients are encouraged to focus on their
of Edward Arnold.) skills and coping resources, not just upon their symptoms and
problem. CBT therapists may also apply techniques aimed at
enhancing motivation, for example by motivational interviews
with patients with substance abuse problems (Marlatt &
Gordon 1985; Miller & Rollnick 2002) or eating disorders
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Psychological therapies CHAPTER 12
(Fairburn et al 2003). The importance of imagery in maintain- getting over-involved with people), but others will be
ing distress has also been realised, i.e. patients may have very dysfunctional (e.g. drug or alcohol misuse).
clear non-verbal and unexamined images which they dare not
reveal, explore or challenge, and yet which may hold the key A clear understanding of the way in which the patient
to treatment success. For example, a woman with an eating characteristically misunderstands relationships (i.e. the trans-
disorder may vividly recall a childhood scene of herself being ference relationships they carry with them) is crucial for
bullied about her weight, the trauma of which may effectively making sense of the patient’s behaviour within therapy and
outweigh any current rationale examination of her symptoms. to understand the feelings the therapist and others develop
Imagery-based CBT would involve helping the patient to alter towards the patient (counter-transference). In addition to
and modify the image, for example by allowing the image to the above psychodynamic understanding, aspects of other
subside by incorporating the presence of a supportive adult models will be used as appropriate – interpersonal psycho-
who can effectively challenge the bullies (Hackmann 1998). therapy, CBT and behaviour therapy, and problem-solving.
Psychoeducation and advice may help treatment compliance,
Finally, some cognitive therapists have acknowledged that a and on occasion it may be helpful to contact others on the
proportion of symptoms do not improve significantly with cog- patient’s behalf or practically assist them in doing so.
nitive therapy, and instead now focus on acceptance and cop-
ing, again by modifying the person’s relationship to their The overall aim is to maintain a positive therapeutic rela-
thoughts about their symptoms. These include mindfulness- tionship, in which the patient feels supported, and therefore
based CBT (Teasdale et al 2000; Segal et al 2001), metacogni- able to accept information about their condition or illness
tive therapy (Wells 2000) and acceptance and commitment as well as about themselves. This is done in a way which
therapy (Hayes & Strosahl 2004), which has been used with encourages maximising positive coping skills and brings an
people who are terminally ill and those with persistant psy- opportunity to learn new ways of coping, intended to minimise
chotic symptoms. The key feature of these therapies is helping more dysfunctional coping methods. Although there will be
the patient to change their thinking about their distressing ups and downs in the therapeutic relationship, the therapist’s
experiences, and hence to reduce their impact. understanding of the psychodynamic formulation should allow
these times to be weathered and perhaps eventually used to
Supportive psychotherapy (SPT) further awareness of how the patient interacts with others.
In turn, the positive relationship, sustained over a long period
SPT is not generally well defined, although the term is usually of time, may support and encourage medication compliance
used to indicate long-term psychotherapy intended to main- and engagement with other treatment aspects.
tain a patient in their current state, or possibly improve them,
and at least to limit or prevent deterioration over time. There The patient characteristics described earlier mean that
is little expectation of bringing about a resolution of deep- those offered SPT may suffer from schizophrenia and severe
seated internal conflicts because of the degree of disturbance affective disorders, severe personality disorders, severe neu-
in the patient. The patient will have a severe and complex roses (including OCD) with underling personality disorders
chronic condition which is unlikely to be helped by, or may and other chronic disorders such as eating disorders.
even be made worse by, more active in-depth psychotherapy.
A background of trauma is common, resulting in a serious Its utility when applied to mental illness in psychiatric reha-
impairment in their ability to develop trusting relationships, bilitation services is described by Meaden and Van Marle
including with the helping professions. The patient has an (2008) and Davenport(2006) and for non-psychotic disorders
on-going need for the reassurance of continued contact with by Hartland (1991). These authors make clear the value of a
the therapist. Frequency of contact is normally between fort- comprehensive formulation not only for the therapist, but also
nightly and monthly, or longer, and may vary depending on for the psychiatric and social care team which is likely to be
how well the patient is functioning at any time. However, involved. Understanding what lies behind the emotional
appointments are booked and not left open so that the patient reactions of staff to the patient is seen as essential if long-term
is able to rely on when they are seeing the therapist. care is to remain therapeutic. SPT is clearly in line with the
Commonly the therapeutic relationship only comes to an end current day ‘recovery’ model.
when either patient or therapist leaves.
The evidence base for SPT lies in observation of case series,
In some aspects SPT resembles a counselling approach case reports and clinical experience. The Finnish needs-
continued over a long period of time. It requires empathy with adapted approach (Alanen 1991/1997) reported reduced
the patient, disclosure and exploration of feelings, with clarifi- admission, reductions in medication use and improved service
cation and, if necessary, confrontation with what is being user satisfaction in a service which uses a psychodynamic over-
avoided. The therapist’s stance should be warm, and genuine, view of the process of care. Randomised controlled trials
with positive regard for the patient as a person in their own (RCTs) are impractical and inappropriate for such long-term
right. approaches (imagine being the patient or therapist randomly
assigned to an unhelpful treatment for 3 years).
The therapist also needs to have a good understanding of
the patient’s personal history, and an awareness of the reper- Counselling
toire of defences (‘coping mechanisms’) that the patient has
built up, some of which can be constructive (e.g. avoiding Counselling is a very broad term, currently applied to almost
any kind of helping activity, some of which is in the mental
health field and therefore a matter of interest for this chapter.
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Companion to Psychiatric Studies
As a broad term it is not easily defined and the boundary with recent onset, but since for many people this condition is self-
psychotherapy may seem vague at times. Counselling is some- limiting, the longer term results suggest no additional benefit
times partly defined by what it is not, or by being contrasted over normal GP care after 6 months (Bower et al 2003). NICE
with psychotherapy on the one hand or with good clinical guidelines on management of depression (2007) and anxiety
concern on the other. (2007) therefore do not recommend counselling for anxiety,
but do include counselling for consideration for mild and
One current definition from the National Institute for moderate depression, although only in early stages. However,
Health and Clinical Excellence (NICE) is ‘. . .a discrete, there may be a tendency to overlook the finding that some
usually time-limited, psychological intervention where the individuals can benefit from counselling in the longer term
intervention may have a facilitating approach often with a (Davis et al 2008).
strong focus on the therapeutic relationship, but may be
structured and at times directive’ and is ‘. . .classified as Systemic and family therapy
counselling if the interventions offered. . .did not fulfil all the
criteria for any other psychological intervention. . .such as cog- Systemic therapy theory
nitive behavioural or interpersonal’. (NICE 2004, amended
2007) The systemic therapies, whether used in the context of indi-
vidual, couple, family, group or institutional work, derive
More simply, with specific reference to grief counselling but broadly from the work of Von Bertalanffy and others in the
in terms which are more generally applicable – ‘Counselling field of general systems theory (GST) (Von Bertalanffy
involves helping people facilitate uncomplicated or normal 1969). The underlying thought behind this model is that the
grief to a healthy completion of the tasks of grieving within a universe is made of systems all with their own underlying
reasonable time frame. . .. the term ‘grief therapy’ is reserved parts, which regularly interact and that can be regarded as
for those specialised techniques. . .which are used to help with being units with their own boundaries, across which informa-
abnormal or complicated grief’ (Worden 1991). This second tion can pass with differing degrees of ease, depending on
definition (there are many more!) conveys the concept that, the permeability of these boundaries. Information in this sense
as humans, we have an innate capacity to adapt to difficulties is regarded as communication, verbal or non-verbal, and thus
and heal, and that counselling aims to provide a situation includes actions.
which mobilises this capacity, allowing the normal adjustment
processes to proceed. These boundaried components are interdependent and
inter-relate to/with one another to try and preserve an under-
The familiar ‘give sorrow words. . .’ (Shakespeare 1603) lying equilibrium by a process of homeostatic regulation.
implies that counselling techniques have been known about When applied to people, these parts can take the form of
for at least 400 years, but it seems generally agreed that Carl different social groups, members of a family or partners in a
Rodgers had a significant impact on the professionalisation couple, etc., which then make up a system. The tendency to
of the concept. He developed his ideas from the early 1940s equilibrium explains why change in one part of a system is
into the 1960s publishing widely on the importance of the often resisted in other parts.
therapeutic relationship and on the healing process. His views
about the transparency and genuineness of the counsellor, and The application of GST to practice
the positive impact of therapist warmth, empathy and uncon-
ditional positive regard have been highly influential and proba- Following from the above, GST can be applied to working
bly regarded by therapists of all persuasions as an essential therapeutically with family systems in particular, as well as
part of any psychotherapeutic method (Rogers 1967). with couples or institutions. A refinement of this theory,
structural family therapy, has been employed by Minuchin
Because of the breadth of the term, it is difficult to typify and Nichols (1998) to consider how boundaries between fam-
what might be called ‘a counselling approach’. There tends to ily members and subsystems of family members can lead to
be an emphasis on listening, with facilitation of the client talk- dysfunctionality, either if too permeable or too rigid. This
ing through the problem area, clarification of thoughts and may appear dysfunctional from the outside but may be acting
feelings, and with further exploration of these. There may be as a function for the family.
some use made of non-verbal expression (pictorial) or writing,
or activities and homework such as visiting a gravesite or going For example, if a child is engaging in school refusal and
through photographs. The intention would be to uncover pain- spending too much time with their mother, i.e. the boundary
ful or other difficult feelings (anger, fear, guilt) in a therapeutic between mother and child has become too diffuse and they
relationship which provides support to the client, enabling have a formed a subsystem, it may appear as if the child has
them to face their feelings and find their own way of resolving the problem. However, by investigating and gathering informa-
them. Sometimes specific psychological interventions may be tion using a systemic family therapy approach, it may become
included such as relaxation techniques. evident that mother is depressed and has previously
threatened suicide and the child is refusing to go to school,
Counselling aims to work with the whole person across a staying at home to keep mother safe – i.e. the ‘maladaptive’
range of the individual’s difficulties and does not generally look behaviour is actually a homeostatic mechanism to preserve
to treat symptom-specific conditions. This means that con-
trolled trials producing the kinds of evidence sought by, for
example, NICE are few. There is evidence for the effective-
ness of counselling in primary care for the treatment of mild
and moderate neurotic disorders (anxiety and depression) of
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Psychological therapies CHAPTER 12
the equilibrium of the system as a whole. In this case, bringing Groups can take a variety of membership formats, which
this information to light may allow the system to reconfigure may be fixed at the outset, or open to new members coming
itself to meet both the child’s and the parent’s needs. and others going over time. The time itself may be limited to
a number of sessions or months. Alternatively the group may
Systemic therapy techniques run on a slow basis which implies a number of years in which
membership may be transient. In light of current pressure on
This group of therapies has a range of unique techniques services to provide psychological therapies for larger numbers
(Crowe 1995) including: of patients, groups are now increasingly seen as a way of
cost-effectively delivering services.
• Paradoxical injunctions – wherein members of the system
are prescribed their symptom that can paradoxically lead to Bion and the basic assumptions
a change in that symptom.
Wilfred Bion pioneered his approach to groups whilst working
• In-session structural interventions – Parts of the system are with soldiers during World War II who were suffering from
assigned different roles, e.g. husband might be asked to ‘shell-shock’. His treatise (Bion 1968) states that all groups
role-play wife. Other interventions might involve the use of are affected by a number of basic assumptions which, in the
a one-way mirror so that those who are enmeshed can step case of groups that are trying to perform a certain task, can
out of their subsystems to see things more objectively, interfere with their functioning. His aim was to help members
or so that trained observers can pinpoint significant family to develop more effective ways of dealing with anxiety and
interaction patterns. hence with life outside the group.
• Reciprocity negotiation – Pragmatic solutions are developed • Basic Assumption Dependency (BaD) – Such groups have a
for problems between members. fantasy that there is a leader amongst them (which may not
be the therapist) who can look after the group and make
• Communication training – Patients are asked to them secure.
acknowledge that they have heard what others have said,
and in turn are asked to communicate clearly their thoughts • Basic Assumption Pairing (BaP) – In this situation two
and feelings. group members will be unknowingly paired up by the group
with an accompanying unconscious belief in the group that
• Homework – Members of the system are assigned tasks to such a union will create some hopeful, miraculous, outcome
complete between sessions which involve a change in their for the group.
actions to see how this affects this system.
• Basic Assumption Fight/Flight (BaF) – The group in this
• Adjust to the symptom – if it appears that the symptom cannot case will perceive that there is a threat nearby which they
be altered, then thought is given on how to live with it. must fight against or flee from.
In addition, simply beginning to clarify with the patients
involved that what may seem like a problem is in fact a solu-
tion to another underlying difficulty can be of clinical benefit.
Other family and couple therapies Yalom and therapeutic factors
Psychoeducation Irvin Yalom described a number of factors (Yalom 2005) that
he felt were universal in helping patients within a group psy-
A psychoeducational approach, in which information is offered chotherapy setting viz a viz working with patients individually
didactically within a CBT framework to families about the (Table 12.3).
nature of psychological disturbances, what styles of interaction
are helpful or hindering, how medication can help and what Group analytic therapy
other treatments are available, can empower patients and their
families to manage psychiatric illness with good effect (B¨auml This school of group psychotherapy was developed by S. H.
2006). Helping families to cope with young psychotic patients, Foulkes (Foulkes 1986) along primarily psychoanalytic and
using a CBT framework, is particularly effective (Burbach systemic principles. He felt that we are embedded in various
&Stanbridge 2007). matrices as we grow and develop. On a macroscopic level,
culture, society and the wider world are known as the founda-
Group therapy tion matrix, but we also find ourselves in family, school and
work matrices as we move through life.
Introduction to group therapy
When patients are then admitted to a therapy group, it can
There are a variety of different schools of group therapy rang- become apparent that they are structuring this new matrix in
ing from the cognitive-behavioural to the psychoanalytic. What ways that mirror their previous experiences in groups. The
links them is that they are all therapies practised by one or therapist or co-therapists, acting more as conductors of an
more therapists with a collection of patients. This allows for orchestra than directive leaders, can then, with other members
not only the therapist-to-patient interaction to shape the ther- of the group who also play a therapist-type role, begin to make
apeutic process but also the patient-to-patient interaction, to sense of how this might be happening in the here-and-now.
act as an agent of possible change. Such repetitions are interpreted which affords insight-driven
change to occur. Group members are selected because they
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Companion to Psychiatric Studies
Table 12.3 Yalom’s therapeutic factors
Therapeutic factor Description
Universality Group members recognise their common experience and how this also reflects wider society’s experience.
This reduces isolation and increases self-esteem
Corrective recapitulation of the primary
family experience Patients unknowingly repeat their experience of growing up in their family with the group and the therapist. This is
Imitative behaviour informed by thoughts about transference, and the therapist may interpret accordingly
Interpersonal learning Through seeing how others interact in the group in terms of listening and communicating helpfully, patients can
Catharsis model their behaviour and become more constructive in their interactions with others
Group cohesiveness
Imparting of information Patients give feedback on how they are perceived by others
Installation of hope
Development of socialising techniques By expressing affect in a supportive environment, patients can feel unburdened of difficult feelings
Existential factors
Self-understanding Members feel a sense of community and integration with others
Altruism
Patients learn from others about practical matters relating to their difficulties.
By seeing other group members improve, patients are instilled with a sense of therapeutic optimism.
The supportive environment of the group allows patients to extend their interpersonal repertoire
The group encourages members to take responsibility for their thoughts, feelings and actions
Patients develop a deeper sense of why and how it is that they interact with others as they do
As patients learn that they can help others, they modify their interpersonal styles and develop a greater sense of
self-esteem
have difficulties in groups, since if this is the location of the CAT is a brief collaborative therapy, focussed on changing
problem, it is best to work there. Additionally members are whatever is causing distress, using both the therapeutic rela-
chosen for their heterogeneity, allowing for a greater variety tionship and discussion, to challenge relationship patterns
of experience and stances with a closer approximation to the (procedures) outside therapy to effect change. A central con-
foundation matrix. cept is that of reciprocal roles, seen as powerful relationship
templates originating in early childhood, which orient the child
There are two particular processes that are also of note: in future relationships, both with others and with the self, in
first, mirroring in which patients will reflect back their experi- self-management procedures. Although these reciprocal roles
ence of one another within the group; second, resonance where are constantly revised through subsequent relationships, they
patients will attune themselves to others’ experience that has strongly influence how the child, and subsequently the adult,
echoes of their own. Group analysts employ the same techni- conducts relationships with significant others, which may in
ques to further understanding and deepen contact between some instances lead to psychological distress and self-defeating
members. behaviour. For example, if a parent is only able to provide
affection for her son conditional on his achievement of aca-
The integrative therapies demic success, and if failure is always scorned, the boy may
have difficulty in learning effective self-soothing, or sensitive
Given growing evidence on the effectiveness of a wide range concern for others who also struggle. As an adult, he may come
of forms of psychological therapy, despite their theoretical for therapy after a series of failed relationships characterised
diversity, a number of integrative therapies have developed by alternating dependence and dismissive rejection. Likewise,
that seek to combine the effective ingredients of a number the child whose needs are ignored by her abusive father, may
of apparently different approaches. The challenge here is to never learn to pay attention to her own needs, nor those of
maximise impact, while maintaining theoretical coherence. her own children. The therapist’s task is to help the patient
Perhaps one of the most successful is cognitive analytic ther- to track and challenge these dysfunctional relationship
apy (CAT) developed by Ryle (1996; Ryle & Kerr 2002), patterns, by discussion of transference and counter transfer-
which aims to integrate an object relations psychodynamic per- ence issues, and by exploring active ways of replacing problem
spective (with an emphasis on the centrality of relationships procedures in the present.
and the transference) with a practical target-focussed CBT
slant. Patient and therapist work collaboratively from a jointly CAT has been applied to a wide range of problems from
written formulation to resolve significantly dysfunctional anxiety, eating disorders and offending behaviour to psychosis
patterns of behaving and relating (known as target problem and self-harm. It is particularly helpful when the patient
procedures). appears to be stuck in self-defeating patterns. It can also be
useful in helping teams within psychiatric services to
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understand why certain patients present significant challenges, positive changes for cognitive therapies than for interpersonal
especially when the team is divided in their approach to therapies, because the items included are more sensitive to
a patient – for example, some staff seeing the patient as a the cognitive therapeutic approach used. Importantly, thera-
‘devious manipulator’ while others see the patient as a ‘tragic pist competence may also vary. Lambert (2007) has shown in
victim’ of abusive circumstances (Murphy & Llewelyn 2007). a series of studies that some therapists are simply more able
to produce effective outcomes than others but as yet we know
Other forms of integrative psychological therapy include very little about exactly what it is that makes the difference.
dialectical behaviour therapy (DBT) (Linehan 1993) which is For example, in one study of 71 therapists using a variety of
particularly helpful for multi-impulsive patients and those approaches, Lambert found that the top 10% of therapists
with personality disorder and/or eating disorders. DBT sees obtained a good improvement rate of 44% with a deterioration
psychopathology as resulting from a possible biological ten- rate of 5%, while the bottom 10% of therapists obtained rates
dency to instability together with a challenging environment. of 28% and 11%, respectively.
It comprises an intensive programme (sometimes up to 2 years)
of individual therapy, social skills training, mindfulness Most crucially perhaps is the fact that for many conditions
meditation, telephone support and group treatment. there is still no evidence-based rubric concerning which
patient is most likely to improve most readily with which type
The evidence-base of treatment delivered by which type of therapist. A compari-
son with general medicine might be that although it is known
Methodological and other issues that antibiotics and insulin are both effective, they are obvi-
ously not interchangeable in their applicability. To ask globally
The crucial question for clinical interventions must of course whether ‘psychological therapy is effective?’ is similarly inap-
be, does it work? There is increasing evidence (reviewed propriate. Unfortunately, assessment of patient-treatment apti-
below) that a range of appropriately conducted psychological tude and of all of the variables which might affect outcome
therapies do have a positive impact on patients and can match including age, problem and personality type is as yet undevel-
the effectiveness of pharmacotherapy for many conditions oped. For clinical practice of course, there are guidelines,
(Dimidjan et al 2006). Likewise, evidence shows that many which are reviewed below. Finally, there has been considerably
therapies that are more effective relative to no treatment or more research carried out on CBT than other forms of psycho-
placebo are also cost effective (Guthrie et al 1999; Leff et al logical therapy, which means that this approach is increasingly
2000), and that gains tend to endure (Lambert & Ogles being seen as the most thoroughly evidence-based and as such
2004, Department of Health 2001). The field is nonetheless attracts more research funding to obtain more evidence.
beset by methodological difficulties. First, it is important to Although there are conditions where CBT does indeed appear
distinguish between efficacy, which is the performance of a to be the treatment of choice based on existing evidence,
treatment in an RCT with highly selected populations, using this does not mean that other approaches are not equally or
strict inclusion and exclusion criteria, and delivered by expert even more effective: it is simply that the research has not
and often closely supervised therapists, versus effectiveness, yet been done.
which is performance in a routine clinical setting, applied to
a mixed patient group, often by therapists who have different Comparative effectiveness and outcome
levels of experience and training, and who may work without
close supervision. Not surprisingly, outcome evidence is stron- Despite these limitations, there has been substantial effort
ger in efficacy trials than in effectiveness trials although trials over a number of decades to establish the comparative effec-
in routine care are often perceived by therapists as having tiveness of different psychological approaches for a range of
considerably more ecological validity (Lambert & Ogles 2004). conditions. The UK Department of Health (2001)’s report
on treatment choice in psychological therapies, the National
Second, much of the recent work in this area has used the Institute for Health and Clinical Excellence (NICE; http://
methodology of meta-analysis, by which the results of many www.nice.org.uk) and the Cochrane Collection (http://www.
studies are combined to calculate effect sizes of particular cochrane.org/) have all reviewed the evidence on effectiveness
treatments. Although useful because a considerable amount and confirmed that a range of psychological treatments are
of evidence can be included, there are difficulties with some indeed effective. These reviews also report a number of RCTs
of the assumptions being made. For example, when comparing broadly favouring CBT treatments, whilst acknowledging that
types of intervention, crucial elements in studies may be not enough research has been done with other approaches.
varied, e.g. in some comparative studies the length of treat- To summarise, the evidence in these reviews suggest that
ment varies from 1 to 1114 sessions (Howard et al. 1986), CBT is possibly more effective for some specific anxiety disor-
which means that like is not being compared with like. Like- ders such as panic, social phobia, OCD, PTSD and generalised
wise some studies use volunteers with minor difficulties such anxiety disorder, as well as for chronic fatigue, bipolar disor-
as public speaking anxiety, which cannot really be compared der, various childhood disorders such as enuresis, bulimia and
with more disabling anxiety problems. Furthermore, the out- depression (Department of Health 2001; Roth & Fonagy
come measurement instruments used vary, and may be crucial. 2004) while psychodynamic and interpersonal therapies may
For example, one widely used measure, the Beck Depression possibly be more effective for borderline personality disorder
Inventory (BDI; Beck et al 1961) is more likely to report and some forms of depression (Bateman & Fonagy 2008a).
311
Companion to Psychiatric Studies
They also note the effectiveness of family-based or systemic produce change. To date, thousands of studies have been
interventions, and counselling, for some conditions. Overall, carried out investigating possible variables which might be
there have been many more studies finding support for CBT expected to impact on therapy including gender, ethnic
than other treatments (evidence for adults with mental health background, age, attitudes, social class and personality of both
problems is reviewed by Roth & Fonagy 2004, while for chil- therapist and patient, although surprisingly few such variables
dren and adolescents, see Carr 2001), but on the other hand, have been found to be robust enough to be supported
studies such as the large-scale US National Institute for across the board (for reviews see Llewelyn & Hardy 2001;
Mental Heath multi-site RCT comparing CBT, interpersonal Orlinsky et al 2004). Nevertheless as noted above one process
therapy, antidepressant medication (imipramine) and clinical variable which is consistently predictive of outcome is the
management for depression, failed to find significant differ- quality of the therapeutic relationship (Orlinsky et al 2004),
ences in outcome between the active treatments over time also known as the working alliance – see ‘The relationship
(Elkin 1989). Likewise, Wampold et al (1997) completed a and therapeutic alliance’ (Horvarth & Greenberg 1994). This
meta-analysis of outcome studies published in established variable appears to act as a prerequisite for change to occur,
journals and reported that the efficacy of bona fide treatments as well as being an early indicator of improvement. Whether
was roughly equivalent. More recently, Stiles et al (2006) it is directly causal is unclear. Some CBT investigators (e.g.
demonstrated that a range of forms of psychotherapy deliv- Tang & DeRubeis 1999) have suggested that positive ratings
ered in routine NHS settings was effective, with a pre-post of the therapeutic relationship result from and are not signifi-
effect size of 1.36. Treatment type (CBT, person-centered cantly causally related to cognitive change and that symptom-
therapy and psychodynamic therapy) only accounted for a atic cognitive improvement is the crucial factor. However,
comparatively tiny proportion of the variance. most investigators agree that the quality of the relationship
or alliance is clearly linked to outcome and is likely to play a
The psychological treatments for adults so far recom- crucial role, even if it is only related to the provision of psycho-
mended by NICE are summarized in Table 12.4 – see http:// logical support and modelling more helpful ways of responding
www.nice.org.uk for full details. to emotion (Gilbert 2007; Norcross 2002). Other process
variables which have been found to be consistently linked to
Process issues good outcome are well-structured treatments, therapies that
are skilfully delivered, therapies that are responsive to patient
Understanding psychological therapy involves not only being requirements and produce positive feelings during sessions,
able to predict outcome (if it works) but also process (how it and approaches that focus on patients’ key problem areas
works). Process studies examine key characteristics and beha- (Orlinsky et al 2004). Finally, therapies are most successful
viours of the therapist, patient and the therapeutic relation- when the patient is reasonably open and ready to change and
ship, in an attempt to distinguish the crucial ingredients that psychologically minded.
Table 12.4 Summary of evidence on effectiveness of psychological therapies
CBT Psychodynamic/interpersonal Counselling Integrative Family
X X X
Psychosis X X X
Anorexia X X X
Bulimia X X
Panic X X
GAD X X
Depression X
PTSD X
OCD X
Bipolar X
CFS X X
Drug misuse X
PD X
CFS, chronic fatigue syndrome; GAD, generalised anxiety disorder; PD, personality disorder.
312
Psychological therapies CHAPTER 12
Much process research is linked to theoretical orientation Table 12.5 Key competencies to be acquired
(e.g. studies within psychodynamic therapy of the impact of
transference interpretations and when and whether these General Specific
have a beneficial impact) while other work is pan-theoretical,
looking for general change processes, seeking to explain how Account for clinical phenomena in Refer appropriately for formal
specific behavioural or cognitive changes come about. For
example, Stiles (2002) developed the assimilation model psychological terms psychotherapies
which documents how problematic experiences are resolved
and assimilated through a series of stages in any type of ther- Deploy advanced communication Jointly manage patients receiving
apy. Other writers have pointed to the tendency of therapists skills psychotherapy
and researchers to overemphasise the professional contribution
to change, suggesting that the crucial factor is the patient’s Display advanced emotional Deliver basic psychotherapeutic
own heroic efforts to understand and get better, often in the intelligence in dealings with treatments and strategies where
face of repeated although presumably unintentional mistakes patients and colleagues and appropriate
and misunderstandings by the therapist (Duncan & Miller yourself
2000). One helpful but relatively new strand of process
research has been the study of ruptures, or therapeutic Higher specialist training
impasses, and how these can either presage premature termi-
nation, or if skillfully handled, can present crucial opportu- Higher specialist training has been in a state of flux in the UK
nities for positive change (Safran & Muran 2000; Bennett over recent years; however, a set of core competencies in the
et al 2006; Leahy 2006). field of psychotherapy have now been agreed (PMETB
2005). This includes:
Training in psychotherapy
• practising psychotherapy for 900 hours under expert
Introduction supervision;
Training in the psychological therapies is a worthwhile experi- • seeing 40 patients for assessment for psychotherapy;
ence both personally and professionally. In light of the fact • formal education in psychotherapy; and
that all interactions can have a potentially therapeutic impact, • other competencies as stipulated in PMETB (2005).
a grounding in the basic principles of interpersonal thinking,
of any school, is of significant importance in the field of Training outside the national health service
psychiatry.
As well as the training that is bound up within progression in
In addition to knowing what psychotherapy works for the NHS, it is possible to commit to external training in any
whom, this is invaluable for practitioners as they continue to of the modalities mentioned above.
develop in their chosen field.
Training in psychoanalytic psychotherapy/
Training within the national psychoanalysis
health service
People who wish to train as psychoanalysts or psychoanalytic
Basic specialist training psychotherapists can apply to training institutes which will
require prospective candidates to pass through a selection
The Royal College of Psychiatrists (2008) has set out a list of procedure involving interviews with members of the training
competencies for psychiatric trainees to attain over the course committee, as well as having some clinical experience already
of their first 3 years of specialist training, with a view to pro- in the mental health field. The candidate will also need to
ducing ‘consultant psychiatrists in all branches of psychiatry show educational attainment to a required standard.
who are psychotherapeutically informed, display advanced
emotional literacy and can deliver some psychological treat- The training itself then involves undergoing personal analy-
ments and interventions’ (see Table 12.5). sis between 3 to 5 times weekly for up to 6 years. During
this time the trainee will attend educational seminars on the
There are three minimum requirements for demonstrating theory and practice of analytic work. Furthermore, they will
attainment of the competencies by ST3 (specialty trainee be required to see a number of cases intensively under super-
doctor year 3): vision. To graduate, a written report on the latter experience
is usually required though assessment procedures vary across
1. complete a psychotherapy ACE; institutes.
2. attend a minimum of 30 case-based discussion groups over
Although involving time and expense, many find it to be a
2 years; and worthwhile experience that can add real depth and under-
3. undertake two psychotherapy cases in two modalities and standing to both everyday psychiatric practice, and any pure
psychoanalytic work that is undertaken. Further information
over two durations between ST1–3. can be found at http://www.psychoanalytic-council.org/main/
index.php?page¼10113.
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Companion to Psychiatric Studies
Training in cognitive-behavioural therapy Access to the next tier is by referral to ‘secondary care’,
commonly a community mental health team (CMHT) com-
Training in CBT is available for members of many professional prised of CPNs, occupational therapists, clinical psychologists
groups, either as a short course during which some techniques and psychiatrists. In the past, referral to this tier would have
may be learned, or as a stand-alone training, or as part of meant referral to a hospital-based service but nowadays, in
another professional qualification. The longer courses, which most areas, this team will operate out of a community base.
may last up to 2 years, aim to help therapists obtain the level This level of service is set up to respond to more acute or
of outcome for patients reported in research trials, and to severe psychiatric illness and psychological problems and pro-
work with more complex needs, using approaches such as vides specialist assessment and treatment for this. This level
schema-focussed therapy. Training normally involves didactic provides psychological therapy, from the aforementioned staff,
training about theory, practice of techniques under observation with longer time-limits and staff who will be more practiced in
or using audio-recording, and subsequent clinical work under working with more severe conditions.
supervision. Personal therapy with CBT is not normally
required. Further information can be obtained from the British The next tier, ‘tertiary care’, involves more specialist clinical
Association of Behavioural and Cognitive Psychotherapies at psychology and psychotherapy services, providing therapies
http://www.babcp.org.uk. to patients referred by secondary care who require more
time and expertise. These services may work together or quite
Training in other modalities independently, but they will offer most of the range of thera-
pies described in this chapter. In addition, many services will
Other trainings are available across the range of schools of subspecialise, offering particular expertise, e.g. in personality
practice. A list, which is not exhaustive, is provided below. disorder, forensic psychotherapy and psychology, eating dis-
orders, child psychology and psychotherapy, therapeutic com-
Group analytic training – http://www.groupanalysis.org/ munities, etc. It is not possible to say definitively what exactly
site/cms/contentChapterView.asp?chapter¼487 is the difference between clinical psychology units and psycho-
CAT training UK – http://www.acat.me.uk therapy units; it is an oversimplification to say that the former
Systems-centered training – http://www.sctri.com/ offer CBT and related integrated therapies and the latter
Training/tabid/4012/Default.aspx psychodynamic psychotherapy, as many of the latter will also
provide CBT, CAT, IPT, EMDR, etc., and a number of clinical
Service issues psychologists are trained in psychodynamic psychotherapy.
Specialist posts for those consultant psychiatrists who have
It is estimated that in the UK at any point one in six of the specialist training in psychotherapy will usually be in psycho-
population has experienced a diagnosable mental health dis- therapy units and they accordingly have a specific role under
order in the preceding month (Singleton et al 2000). Most of the requirements of the Royal College of Psychiatrists in the
this morbidity is due to anxiety and depression, at a mild training of psychiatrists. It may be that the separation of
and moderate level. A small proportion will suffer from severe services is more a function of separate professional identities.
psychiatric disorders and be referred directly to the specialist
psychiatric services. What happens to those suffering from The above ‘tertiary care’ tier will normally be the first ser-
mild and moderate disorders is very variable depending on vice where the patient and referrer will come up against a very
the local circumstances which determine the availability of significant waiting time, sometimes more than a year. This is
NHS, voluntary sector, local authority and private facilities. clearly a challenge for NHS funding, senior managers and the
The permutations are virtually endless, may occur in any order services themselves, and there appears to be some mismatch
and are too complex to cover comprehensively in this chapter. between provision and demand for services at this level.
In terms of health policy, there is currently a strong central
It has become common to consider the NHS provision as a government drive to expand the service provision at commu-
tiered service. The shape of this varies from place to place and nity and primary care levels, hoping to reduce the need to
what follows is an outline of one possible structure. The refer to higher tiers.
description may also give the idea that progress through the
tiers is an orderly well-defined matter, but those working in At the service level, in order to protect what is a scarce
the service will be aware that this is rarely the case. resource for those who need treatment at this tier, a number
of ‘demand management’ methods may be employed, for
At the first tier, i.e. the community level (may be referred example:
to as tier one or tier zero), there is a range of self-help, guided
self-help, web-based self-help and computer-aided CBT • information for referrers to assist in the referral to patients
which may also be available. The next tier, primary care level likely to benefit;
(GP/health centre-based services), includes advice and/or
medication, counselling, behaviour therapy, CBT or IPT from • ‘opt-in’ arrangements – patients are required to actively
a community psychiatric nurse (CPN), clinical psychologist respond to contact from the service before an appointment
or other professional, and some areas have a separate system is offered;
for this. In most cases the conditions are self-limiting and the
extent to which a more specific psychological therapy is useful • postal questionnaires which confirm the required level of
remains a matter of debate (see ‘Counselling’). severity; and
• times in the week put aside for consultation/liaison with
potential referrers so that they can telephone the service for
advice about a referral.
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Psychological therapies CHAPTER 12
In addition to the provision of a direct service to patients, In recent years, training courses have been running, and new
these specialist services offer consultation and training to staff jobs have been created, for a new breed of psychological ther-
in the lower tiers and also work with staff in in-patient services, apist to undertake front-line therapy. In addition, primary care
either regarding referrals of patients or in supporting staff in mental health staff are all being trained in psychotherapy
work in this area (Hook 2001). Due to the numbers of patients (mostly CBT), and all of these staff will require at least a basic
referred and treated these units offer rich opportunities, in col- level of support and supervision for their work. This may mean
laboration with university departments of psychiatry, for audit for some time to come that specialist units will be expected to
and research in the psychological therapies, and for training in shift time into training, support and supervision at the primary
psychotherapy research methodology (Margison et al 2000). care level. At the specialist psychotherapy (tier 4) level there
could be a resulting drop in demand, or alternatively the new
Conclusion tier 0 and 1 services will be reaching a population that has
heretofore been denied a psychotherapy service. If the latter
At the time of writing both the Department of Health for is the case then waiting times at tier 4 will not be reduced or
England and Wales and the Scottish Parliament are responding may even increase.
to public concern about the proper balance between medica-
tion and psychotherapy in the treatments commonly provided There are both new and existing service needs at specialist
for mental health disorders. Access to psychological therapies level. The principles behind the new Scottish Mental Health
is now well up on the agenda. In Scotland, the NHS Mental (Care and Treatment) Act (2003) include ‘reciprocity’: a person
Health Delivery Plan, and in England and Wales, the Depart- detained under the Act and thereby deprived of their liberty
ment of Health, are driving this forward, the latter having allo- should receive the treatments needed to help them to recover.
cated £173m for the purpose (Department of Health 2008). Psychological therapies are specifically referred to in the Act
The focus is mainly on the provision at the primary care level, as treatments to be provided. Detained patients are seriously
but is also aiming to reduce the distinction between primary ill and carry significant risk – their treatment often needs specia-
and secondary care. lists. Similarly government concerns about ‘dangerous and
severe personality disorder’ are requiring the setting up of new
This chapter describes psychotherapies of different modal- services, some within forensic psychiatry, also a specialist ser-
ities and orientations; does it then follow that the practitioners vice. In all tiers above the primary care level, there are needs
and services must be split up along these lines? Professional across almost every psychiatric specialty for psychotherapy,
rivalries may seem to be ubiquitous, but our own experience not only for adults, but also for the young and the elderly. Nor
is how much less an issue this is when the various professionals are the symptoms of psychological difficulty confined to psychi-
are in the same room discussing clinical work – nobody has all atric services, as there are many patients referred to medical and
the answers and all views seem worthy of consideration. Rigid surgical services where psychological problems are either a sig-
belief in a single model being a ‘cure all’ is not supported by nificant factor in their illness or the major factor. Not all thera-
research or clinical experience. Individual therapists are better pists need to be trained to the highest levels, but some do, in
at one type of therapy than another, and some are better than what might be referred to as a ‘mixed economy’ of different
others when doing the same therapy (see ‘The evidence-base’). grades of expertise and a choice of therapies.
How much rigid treatment model adherence is there in day-
to-day clinical practice, and to what extent does everyone These changes bring challenges, but the public’s concern
become eclectic? There are no clear answers to these questions. about the availability of psychotherapy means that even in
the present difficult financial climate these challenges cannot
be ignored.
Further reading
Alanen, Y.O., 1997. Schizophrenia: Its Origins handbook of psychotherapy and behaviour Interpersonal Therapy (PIT) in Routine
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Lambert, M.J., Ogles, B.M., 2004. The Efficacy Paley, G., Cahill, J., Barkham, M., Shapiro, D.,
and Effectiveness of Psychotherapy. In: Jones, J., Patrick, S., et al., 2008. The
Lambert, M.J. (Ed.), Bergin and Garfield’s Effectiveness of Psychodynamic-
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318
Organic disorders 13
Alan J Carson Adam Zeman Tom Brown
Introduction factors driving disability and handicap. Hence psychological,
environmental and social interventions are as important in
At the interface between psychiatry and neurology lies a range the management of the organic disorders as pharmacology.
of disorders that have been traditionally termed ‘organic’ in The principles behind psychological and behavioural inter-
order to differentiate them from functional psychiatric disor- ventions are described in Chapter 12. In this chapter we con-
ders such as schizophrenia. Scientific advances have rendered centrate on pharmacological interventions but hope the reader
this distinction an anachronism (Lipkin 1969) as few would will understand that both assessment and management require
dispute that organic changes in the brain underpin the psycho- an appropriate multidisciplinary contribution.
pathology of traditional ‘functional’ disorders such as schizo-
phrenia. And ironically, much less is understood about the Clinical assessment
neuropathology of many of the traditional ‘organic’ disorders,
such as Gilles de la Tourette’s syndrome, than about those A systematic approach to clinical assessment is the basis of
disorders previously regarded as ‘functional’. Although dis- safe and effective practice (see also Chapter 10).
carded in DSM-IV the category of ‘organic disorders’ has been
retained in ICD-10 (F00-F09) and consequently we use it Mental state examination
here. This chapter broadly follows the ICD-10 classification
(Box 13.1). Dementias are covered in Chapter 22. In relation The mental state examination in neuropsychiatry follows the
to ‘Other mental disorders due to brain damage and dysfunc- principles described in Chapter 10, however some special
tion and to physical disease (F06.0–9)’, we have described considerations have to be made as the patient’s neurological
the cognitive and psychological consequences of common neu- condition often directly affects the expression of emotion.
rological disorders that the psychiatrist is likely to encounter. A detailed discussion of the effects of specific lesions on emo-
tion and behaviour can be found in Bougasslavsky & Cummings
Clinical practice at this interface between psychiatry and (2000).
neurology is often called neuropsychiatry. Neuropsychiatry is
based on: (a) a systematic clinical approach to patient assess- Aphasia
ment, based on the known psychological and behavioural cor-
relates of damage to different parts of the brain (Fig. 13.1); Global aphasia leads to the abolition of all linguistic faculties,
and (b) a clinical assessment not only of this impairment but and recording of mood and emotion is speculative. Some
also of the psychological and social factors associated with accounts associate Broca’s aphasia with intense emotional
the subsequent disability and handicap (Box 13.2). frustration that may be secondary to problems in social inter-
action, and Wernicke’s aphasia may be associated with lack
This two-pronged assessment will generate both a diagnosis of insight, irritability and rage, with recovered patients report-
and a problem list. Together they form the essential pre- ing that they thought their examiner was being deliberately
requisite for the drawing up of individually tailored manage- incomprehensible.
ment plans. Because in many cases our ability to reverse the
neuropathology giving rise to the impairment is limited, man-
agement focuses on addressing the psychological and social
ã 2010, Elsevier Ltd.
DOI: 10.1016/B978-0-7020-3137-3.00013-9
Companion to Psychiatric Studies
Box 13.1 is perhaps most described, but it can affect any function and
is commonly associated with visual and language function.
ICD-10 organic disorders It occurs more frequently with right-sided lesions, particularly
in middle cerebral artery territory.
F00–F09
Affective dysprosodia
Organic, including symptomatic, mental disorders
F00 Dementia in Alzheimer’s disease Affective dysprosodia is the impairment of the production
F01 Vascular dementia and comprehension of language components which allow the
F02 Dementia in other diseases classified elsewhere (Includes communication of inner emotional states in speech, such as
stresses, pauses, cadences, accent, melody and intonation. Its
dementia in Pick’s disease, Creutzfeldt–Jakob disease, presence is not associated with an actual deficit in the ability
Huntington’s disease, Parkinson’s disease and human to experience emotions, just in the ability to communicate
immunodeficiency virus (HIV) disease) or recognise them in the speech of others. It is particularly
F03 Unspecified dementia associated with right-sided lesions.
F04 Organic amnesic syndrome, not induced by alcohol and
other psychoactive substances Apathy
F05 Delirium, not induced by alcohol and other psychoactive
substances Apathy manifests as reduced spontaneous actions or speech,
F06 Other mental disorders due to brain damage and and delayed, short, slow or absent responses. Apathy is fre-
dysfunction and to physical disease (Includes organic quently associated with hypophonia, perseverations, grasp
psychoses and organic mood disorder) reflex, compulsive manipulations, cognitive and functional
F07 Personality and behavioural disorders due to brain disease, impairment and older age. Hypoactivity of frontal and anterior
damage and dysfunction (Includes organic personality temporal regions has been observed.
disorder, postencephalitic syndrome and postconcussional
syndrome)
F09 Unspecified organic or symptomatic mental disorder
Executive function Praxis Perceptuo- Emotional lability
‘Frontal lobe syndrome’ Apraxia spatial function
Emotionalism or emotional lability, with an increase in laugh-
Agnosia ing or crying with little or no warning signals, is frequent after
Spatial disorientation stroke and after traumatic brain injury. There is an association
with depression but the two can exist independently (House
et al 1989). It has been suggested that the abnormality is
serotonergic and that there is a specific response to SSRIs.
Memory Language Catastrophic reactions
Amnesia Aphasia
Alexia Catastrophic reactions manifest as disruptive emotional
Agraphia behaviour when a patient finds a task unsolvable. They are
often associated with aphasia and it has been suggested that
Fig. 13.1 Functional topography of the cerebral cortex, and the damage to language areas is a critical part of the aetiology.
various syndromes that arise from impairment in particular areas. They generally exist independent of depression, but many
patients showing catastrophic reactions will over time develop
depression.
Box 13.2 Cognitive examination
WHO definitions of impairment, disability and handicap The cognitive examination is described briefly in Chapter 10.
A somewhat more detailed description is given here as it is
Impairment: The loss or abnormality of structure or function central to the assessment of organic disorders. It is organised
Disability: The restriction or lack of ability to perform an according to the capacities it aims to assess, as follows.
activity in the manner or within the range
Handicap: considered normal for a human being Wakefulness
The disadvantage for an individual that prevents or
limits the performance of a role that is normal for Wakefulness depends on normal cerebral arousal by the brain-
that individual stem and thalamic ascending activating system. A subject
whose conscious level is impaired will inevitably perform
Anosognosia poorly on cognitive testing. The Glasgow Coma Scale (GCS)
provides a widely used assessment tool which uses three para-
Anosognosia refers to partial or complete unawareness of a def- meters: eye opening, verbal responses and motor behaviour
icit. It may coexist with depression, suggesting two separate (Table 13.1).
systems for emotional assessment. Anosognosia for hemiplegia
320
Organic disorders CHAPTER 13
Table 13.1 The Glasgow Coma Scale Memory
Feature Scale responses Score
Eye opening Spontaneous 4 Explicit Implicit
Best verbal response To speech 3 (declarative) (procedural)
To pain 2
None 1 STM LTM Conditioning Priming Motor
(working) skills
Orientated 6
Confused conversation 4 Verbal Spatial Episodic Semantic
Words (inappropriate) 3 (event) (fact)
Sounds (incomprehensible) 2
None 1
Best motor response Obey commands 5 Fig. 13.2 A taxonomy of memory. LTM, long-term memory; STM,
Total coma ‘score’ Localise pain 4 short-term memory.
Flexion to pain 3
Abnormal flexion 2 example remembering a telephone number from looking it
Extension to pain 2 up in the directory to dialling it. Long-term declarative
None 1 memory is divided into episodic, the memory for unique
events like your last holiday, and semantic, the database of
3–15 knowledge about language and the world which we con-
stantly use to interpret what we perceive. These distinctions
Orientation have a neurobiological basis. Working memory depends on
frontal executive structures which direct attention, and pos-
Orientation in place and time depends on multiple psycho- terior areas relevant to the material being rehearsed. The
logical functions, and a finding of disorientation therefore acquisition of new long-term declarative memories requires
implies cognitive failure in one or several domains. It is the integrity of limbic regions connected in the ‘circuit of
helpful to test orientation near the start of the cognitive Papez’ (Fig. 13.3), particularly the hippocampus and adja-
examination. cent structures in the medial temporal lobes, the fornix
and the anteromedial thalamus. Damage to these structures
Attention underlies the classical ‘amnestic syndrome’. Procedural
memory is substantially independent of declarative memory
Attention can be ‘sustained’, ‘selective’, ‘divided’ or ‘prepa- and is based in different brain structures – including the cer-
ratory’ or classified in terms of its object, for example ebellum, which mediates classical conditioning, and the
‘spatial’ and ‘non-spatial’. The form most relevant to the basal ganglia.
cognitive examination is the sustained attention that allows
us to concentrate, which depends on the concerted func- Memory is usually tested clinically by asking the patient
tioning of a number of brain regions, including subcortical to register information, such as a name and address or three
arousal centres, frontal ‘executive’ regions and posterior words (working memory), and to recall the same informa-
sensory or language areas. Disruption of attention – often tion after an interval of at least 1 minute, while performing
by factors that disturb brain function in a diffuse way, such other mental tasks to prevent rehearsal. General knowledge
as drugs, infection or organ failure – is the hallmark of a con-
fusional state or ‘delirium’. Sustained attention is best Fornix
tested using moderately demanding, non-automatic tasks
like reciting the months backwards or, as described in the Thalamus
Mini Mental State Examination (MMSE) (Folstein et al ant. DMN
1975), spelling WORLD backwards or subtracting 7 serially
from 100.
Memory Mamillary body
Figure 13.2 depicts a widely accepted taxonomy of memory. Amygdala Hippocampus
There is an important distinction between explicit or declar- Parahippocampal
ative memory and implicit or procedural memory. Declara-
tive memories can be articulated whereas procedural gyrus
memories are enacted, as when, for example you ride a bicy-
cle. Working (or ‘short-term’) declarative memory allows Fig. 13.3 Schematic diagram of the ‘circuit of Papez’ linking limbic
you to keep information in mind while you use it, for structures essential to the formation of new long-term declarative
memories. ant. DMN, anterior and dorsomedial nuclei.
321
Companion to Psychiatric Studies
questions are often asked to tap semantic memory (which is areas critical for language cluster around the Sylvian fissure
also probed by questions requiring visual recognition and (‘perisylvian area’), and include three main components:
naming).
• Broca’s area in the inferior frontal lobe, required for fluent
Executive function language production;
‘Executive function’ refers to the complex of abilities which • Wernicke’s area, in the posterior superior temporal lobe,
allow us to plan, initiate, organise and monitor our thoughts required for language comprehension; and
and behaviour. These abilities, which are located mainly in
the frontal lobes, are essential for normal social performance. • the arcuate fasciculus, the white matter tract which
Functional subdivisions are recognised within the frontal lobes. connects them.
Motor and premotor areas in and adjacent to Brodmann Area
4 more or less directly govern movement. Dorsolateral pre- Damage to Broca’s area causes dysphasia characterised by
frontal cortex, lying anterior to motor and premotor cortex, effortful, dysfluent speech with reduced use of ‘function
is particularly involved in attention, working memory and words’ (prepositions, articles, etc.) and ‘phonemic paraphasias’
organisation of thought and behaviour; orbitofrontal cortex is (incorrect words approximating to the correct one in sound),
concerned with regulation of social behaviour; medial frontal with well-preserved comprehension. Damage to Wernicke’s
cortex, including the anterior cingulate gyrus, is closely area produces a dysphasia characterised by fluent speech with
connected to the limbic system and integrates motivation both phonemic and semantic paraphasias (incorrect words
and arousal with cognitive function. approximating to the correct one in meaning) and poor com-
prehension. The stream of incoherent speech and lack of
Frontal lobe disorders are notoriously difficult to test but insight in patients with Wernicke’s dysphasia sometimes leads
often make themselves apparent in social interaction with to misdiagnosis of a primary thought disorder and conse-
the patient. Specific tasks which can be used to clarify deficits quently to a general psychiatric referral: the clue to the diagno-
in frontal lobe function include: sis of a language disorder in such cases is the severity of the
comprehension deficit. Global dysphasia combines features
• verbal fluency, for example listing as many animals as of Broca’s and Wernicke’s dysphasias. Damage to the arcuate
possible in 1 minute; fasciculus leads to a conduction aphasia in which speech is nor-
mal but repetition markedly defective. The non-dominant
• motor sequencing, for example asking a patient to copy hemisphere also plays a part in speech by enabling the appreci-
a sequence of three hand positions; ation of the emotional overtones of language.
• the go–no-go task, requiring the patient to tap the desk When assessing dysphasia, first listen to the characteristics
once if the examiner taps once, but not to tap if the of the patient’s speech (is it dysfluent or paraphasic?), then
examiner taps twice; and assess their comprehension. Naming is impaired in both major
varieties of dysphasia, and ‘anomia’ can be the clue to mild
• tests of abstraction (‘what do a tree and a snail have in dysphasia. Selective impairment of repetition characterises
common?’). ‘conduction aphasia’. In ‘transcortical’ dysphasia, repetition is
spared, but damage closely adjacent to Broca’s or Wernicke’s
Language area causes patterns of deficit otherwise typical of Broca’s or
Wernicke’s dysphasia. It can also be helpful to assess reading
The left hemisphere is dominant for language in almost all and writing ability. The main dysphasic syndromes are
right-handed persons and also in most left-handers. The brain described in Table 13.2.
Table 13.2 Classification of dysphasic syndromes
Aphasia type Fluency Comprehension Repetition Naming
þ
Global þ þ þ þ
Broca’s þ – þ þ
Wernicke’s – þ þ þ
Conduction – – þ þ
Transcortical sensory – þ – þ
Transcortical motor þ – – þ
Anomic – – –
þ, affected; –, relatively spared.
After Hodges (1994).
322
Organic disorders CHAPTER 13
Arithmetic for psychiatrists is described in Chapter 10. Here we highlight
some findings of particular relevance to the assessment of
Arithmetical skills are located in the dominant hemisphere, organic psychiatric disorders.
particularly in the region of the angular gyrus, in the inferior
parietal lobe. Damage to the angular gyrus gives rise to Dyskinesias
Gerstmann’s syndrome of dyscalculia, dysgraphia (difficulty
with writing), confusion of left and right and ‘finger agnosia’ Involuntary – or semi-voluntary – movements of face, trunk or
(difficulty in identifying individual fingers). limbs are known as ‘dyskinesias’. The family of dyskinesias
includes several types:
Praxis
• Tics are habitual, usually jerky, movements which can be
‘Praxis’ refers to the ability to perform skilled actions. Dys- voluntarily suppressed for a time.
praxia is the inability to perform skilled actions despite intact
basic motor and sensory abilities. Knowledge of how to do • Myoclonus describes rapid, ‘shock-like’ muscle contractions
such things as use a screwdriver or brush teeth depends on which can be focal or generalised (we all experience
areas in the frontal and parietal lobes of the dominant hemi- generalised myoclonus from time to time as we drop off to
sphere. Dysphasia and dyspraxia often occur together. These sleep).
abilities can be tested by asking a subject to mime actions,
and by asking him or her to copy unfamiliar hand positions. • Tremor is rhythmic alternating contraction of agonist and
antagonist muscles, occurring with the arms outstretched in
‘Gait apraxia’ is difficulty in initiating and maintaining gait ‘postural tremor’, often due to benign familial tremor, or at
despite intact basic motor function of the legs, and is asso- rest in the pill-rolling tremor of Parkinson’s disease, or
ciated with bilateral medial frontal pathology, caused, for when nearing a target in the ‘intention tremor’ of cerebellar
example, by hydrocephalus. disease.
‘Dressing apraxia’ describes a difficulty in dressing caused • Chorea describes the fidgety, changeful, distal movements
by inability to puzzle out the spatial arrangement of clothes which accompany some disorders of the basal ganglia such
in relation to the body and is a perceptual rather than a motor as Huntington’s disease (hemiballismus is its pathological
dysfunction. extreme).
Perception • Dystonia, relatively sustained abnormalities of posture,
occurring focally in writer’s cramp or torticollis, globally in
The right hemisphere is ‘dominant’ in tasks requiring an appre- generalised dystonia, is also thought to reflect basal ganglia
ciation of spatial relationships. The syndrome of ‘neglect’ dysfunction (athetosis is its distal equivalent).
involves a failure to attend to or act towards the side of space
contralateral to a brain lesion; as this is usually in the right • Tardive orofacial dyskinesia sometimes induced by
hemisphere, it is usually the left side of space that is neglected. antipsychotics is particularly familiar to psychiatrists.
The right hemisphere is also dominant in other perceptual
tasks. ‘Prosopagnosia’, for example, a selective difficulty in Abnormalities of gait
recognising familiar faces, is more common after right than left
hemisphere damage. Agnosia is difficulty in recognising objects Characteristic patterns include:
where basic sensory functions are intact. Agnosia can be ‘apper-
ceptive’, if relatively ‘early’ processes of percept formation • the flexed, unsteady, small-stepping gait of Parkinson’s
are involved, or ‘associative’ if the failure lies in perceptual disease with diminished arm swing;
memory. Associative agnosias merge into deficits of semantic
memory. Perception is tested using naming tasks, which • the broad based, unsteady gait of cerebellar disease;
depend on both recognition and name finding, and by testing • the lurching, chaotic gait of Huntington’s chorea;
copying, which taps perceptual as well as motor processes. • the stiff-legged, scissoring gait of upper motor neuron
dysfunction (‘spasticity’);
• the failure of ‘gait ignition’ in gait apraxia, due for example
to hydrocephalus; and
• the high-stepping gait accompanying foot drop.
Standard assessment instruments Abnormalities of visual fields and eye movements
The Mini-Mental State Examination (MMSE) (Folstein et al Markedly reduced acuity of recent onset should raise suspicion
1975) is the most widely used brief instrument. The Adden- of a central scotoma linked to optic nerve disease, for example
brooke’s Cognitive Examination (Revised) is a more extensive in multiple sclerosis. A hemianopia to left or to right present in
‘bed-side’ battery (Mioshi et al 2006). both eyes’ fields (‘homonymous’) points to pathology behind
the optic chiasm, probably within the hemispheres. A hemiano-
Neurological examination pia affecting the temporal field in each eye (bitemporal) sug-
gests pathology at the chiasm, most often due to compression
Psychiatrists should be able to perform a competent basic neu- by a pituitary tumour.
rological examination, as this often provides the crucial clues
to a neuropsychiatric diagnosis. A neurological examination Palsies of gaze, for example inability to direct either eye
to one side, indicate pathology in the brainstem or in tracts
descending to the brainstem from the hemispheres. Inability
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Companion to Psychiatric Studies
to trigger rapid voluntary vertical eye movements (‘saccadic’ Lower motor neuron signs
movements) is an early feature of progressive supranuclear
palsy. These result from disorders affecting the brainstem, spinal
cord or peripheral nerves, for example in patients with periph-
Pyramidal signs eral neuropathies. The signs are muscle wasting and fascicula-
tion, muscle weakness which is often generalised and loss
Dysfunction of the ‘pyramidal tracts’, the direct descend- of reflexes. Disorders causing lower motor neuron signs can
ing pathway from the motor cortex to the brainstem and also be associated with impairment of brain function, for
spinal cord, gives rise to ‘upper motor neuron signs’. These example in dementia associated with motor neuron disease,
are increased tone in the limbs with a ‘clasp-knife’ or ‘catch- leucodystrophies and HIV infection.
and-give’ quality, weakness particularly affecting extensor
muscles in the arms and flexors in the legs, excessively brisk Sensory signs
reflexes and extensor (upgoing) plantar reflexes. Such signs
are commonly seen after stroke and in multiple sclerosis. Sensory signs are generally the least reliable or helpful neuro-
Pyramidal signs in the limbs may be associated with ‘pyrami- logical findings. They can, however, occasionally give useful
dal’ dysfunction of bulbar muscles (a ‘pseudo-bulbar palsy’, clues — as, for example, loss of joint position and vibration
giving rise to dysphagia and dysarthria), and with lability sense in a patient with dementia due to vitamin B12 deficiency.
of emotional expression or ‘pseudo-bulbar affect’ (easily
provoked ‘pathological’ crying). General medical examination
Frontal ‘release’ signs Like the neurological examination, a careful general medical
examination should be a routine part of the assessment of
Certain ‘primitive’ reflexes can be released by impairment of organic psychiatric disorders. The cause of dementia, for
frontal lobe function. These include the pout reflex (a pouting example, may come to light when pallor (due to the anaemia
movement stimulated by stroking the upper lip or tapping the of vitamin B12 deficiency), lymphadenopathy (associated with
lips), the grasp reflex (flexion of the patient’s hand around HIV infection), slow pulse (of hypothyroidism), hypertension
the examiner’s finger despite a request ‘not to grip’) and the (causing subcortical ischaemia) or a testicular tumour (asso-
palmomental reflex (puckering of the ipsilateral chin in ciated with paraneoplastic limbic encephalitis) is detected.
response to drawing an orange stick briskly across the thenar
eminence). These reflexes should be regarded as abnormal in The dementias
young adult patients, but can return with advancing age. They
may accompany the behavioural abnormalities associated with Definition
the frontal lobes or their connections.
Dementia is defined as a syndrome due to disease of the brain,
Extrapyramidal signs usually of chronic or progressive nature, in which there is dis-
turbance of multiple higher cortical functions but no clouding
Dysfunction of the basal ganglia (caudate, putamen, globus of consciousness. The nature and management of the senile
pallidus and linked subcortical regions) can cause either a dementias of Alzheimer’s, vascular, and Lewy body types are
‘negative’ or a ‘positive’ neurological syndrome. The negative described in Chapter 22.
syndrome is typified by Parkinson’s disease, with difficulty
in initiating and slowness in performing movements (brady- A clinical approach to the diagnosis
kinesia), reduction of automatic movements such as facial of dementia
expression and arm swing, increased limb tone with a ‘lead-
pipe’ or cogwheeling quality (rigidity), rest tremor and postural Careful clinical assessment will reveal the diagnosis in the
instability. The positive syndrome, typified by Huntington’s majority of patients with complaints which raise a suspicion
disease, or overtreated Parkinson’s disease, involves an excess of dementia and should include:
of movement with choreo-athetosis. The neurological signs of • a history-taking from the patient, which both supplies
basal ganglia disease are often accompanied by psychological
symptoms such as slowing of cognition in Parkinson’s disease relevant factual information and provides an opportunity to
and impulsivity in Huntington’s chorea. appraise cognitive function;
• a history from an informant, which is essential in the
Cerebellar signs assessment of all patients with cognitive complaints; and
• a general medical, neurological and mental-state assessment
Cerebellar dysfunction impairs the coordination of movement. including a cognitive examination.
Signs include nystagmus, dysarthria, gait ataxia, incoordination In our own memory clinic this assessment is performed
of limb movements (e.g. ‘finger–nose’) and impairment of jointly by a neurologist and a psychiatrist who see patients
rapid alternating movements (e.g. tapping with one hand on consecutively; the total assessment takes around 90 minutes.
the upper and lower surface of the other hand alternately).
The role of the cerebellum in coordinating thought and
emotion as well as movement is a focus of current research.
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Organic disorders CHAPTER 13
Three key questions need to be answered by the clinical Box 13.3
assessment:
History-taking in dementia
• Is there a significant cognitive problem? A proportion of the
patients referred will be ‘worried well’; if so, clinical Enquire (from patient, informant or both) about:
assessment and reassurance may be all that is needed. • Course and duration of symptoms
• Cognitive symptoms:
• Is there a psychiatric diagnosis other than dementia, in
particular does the patient have a depressive or anxiety —Concentration: ?absent mindedness and slips of attention
disorder? The presence of these does not rule out —Memory: episodic, semantic
concomitant dementia, but early recognition of psychiatric —Executive function: planning and organisation of activities
disorder is helpful, as it may be treated. Sometimes the —Language: word-finding, comprehension, reading, writing
mood disorder will turn out to lie at the root of the —Calculation: finances
cognitive symptoms. —Spatial/perceptual function: route finding, face recognition
—Praxis: ?preserved motor skills
• If dementia is present, what is its cause? Will clinical • Psychological and behavioural symptoms:
assessment and ‘standard’ investigations (see below) suffice —Personality change
to establish a specific diagnosis, or is a more intensive —Mood disturbance
approach required? —Psychotic phenomena
—Altered eating habits
History-taking —Sleep disturbance
—Altered sexual behaviour
As well as documenting the details of the cognitive disorder, it • Activities of daily living:
is important to obtain a good background medical and psychi- —Washing
atric history, including previous episodes of affective illness, a —Dressing
history of vascular disease or the consumption of prescribed or —Shopping
recreational drugs. Each of these could point to the cause of a —Cooking
patient’s cognitive impairment. Both patient and informant —Housework
should be interviewed alone. We generally find it convenient —Work
to take the initial history with both present, then to interview —Driving
the informant alone, and finally to perform the examination —Hobbies
with the patient alone. The aspects of the history to be —Social activities
covered are listed in Box 13.3.
Examination More intensive investigation will generally be required if an
unusual cause is suspected. The clinical features which should
The approach to clinical examination is outlined above and in excite suspicion of an unusual cause include:
Chapter 10. However, it should be remembered that both a
general medical and neurological examination is required. • early onset (under the age of 65);
The medical examination may contribute important diagnostic • rapid progression (beyond the approximate 3-point annual
information. The mental-state examination should always
include a cognitive assessment. While the MMSE is the mini- decrement on the MMSE which is expected in Alzheimer’s
mum required, it should be remembered that it is insensitive disease);
to early cognitive decline in people with high IQ, and also
insensitive to impairment in some cognitive domains, for • a family history of the presence of systemic or neurological
example praxis and executive function. We have described features other than those associated with the three
supplements to the MMSE above. common dementias; and
Investigations Box 13.4
Where the clinical assessment suggests that a dementia is ‘Standard’ investigations in dementia
likely, most patients will be suffering from one of the three
most common causes: Alzheimer’s disease, vascular dementia • Neuroimaging:
or Lewy body disease. If the clinical features are in keeping —CT or MRI
with one of these diagnoses, a set of ‘standard’ investigations
(Box 13.4) will generally suffice to support the diagnosis and • Blood screen:
exclude several of the more readily reversible causes of —FBC, ESR
dementia (Box 13.5). These relatively inexpensive tests should —UþE, LFT, Ca
be performed unless there is a good reason not to. It is a moot —Glucose, cholesterol
point whether formal neuropsychological testing should always —B12 and folate
be requested; careful ‘bedside’ cognitive assessment is often —Thyroid function
sufficient in straightforward cases. —Syphilis serology
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Companion to Psychiatric Studies
Box 13.5 and dementia (Table 13.3). The presence of dementia is a risk
factor for delirium, and some dementing illnesses, notably
Reversible causes of dementia Lewy body disease, incorporate elements of delirium. How-
ever, the causes and management of delirium and dementia
• Wilson’s disease are largely distinct, and the separation is therefore useful.
• Whipple’s disease
• Hashimoto’s encephalopathy The second distinction is between cortical and subcortical
• Vasculitis dementias (Table 13.4). Cortical dementias, such as Alzheimer’s
• Hydrocephalus, chronic subdurals, benign CNS tumours disease, and some cases of cerebrovascular dementia, disrupt
• Hypothyroidism the ‘modules’ of cognitive function identified in the first
• Vitamin deficiencies, e.g. B12 deficiency section of this chapter – language, praxis, perception, etc.
• Prescribed and recreational drugs The classical syndromes of ‘dysphasia’, ‘dyspraxia’, ‘agnosia’
• Obstructive sleep apnoea ensue. In subcortical dementias these cortical functions remain
• Depression more or less intact, but their subcortical activation and inter-
action are impaired: the cardinal feature of the resulting
NB: This list highlights causes which can sometimes be reversed; several other cognitive impairment is slowness, often accompanied by beha-
causes of dementia can be treated medically with some success, e.g. Alzheimer’s vioural change reminiscent of the apathy and inertia which
disease, Lewy body disease and HIV-related dementia. can follow damage to the frontal lobes. Subcortical cogni-
tive impairment of this kind is seen in disorders as varied as
• the presence of certain distinctive combinations of features: ‘small vessel’ cerebrovascular disease, multiple sclerosis, HIV
for example, limb apraxia, myoclonus and alien limb infection, Huntington’s disease and progressive supranuclear
phenomena in corticobasal degeneration; or dysarthria, palsy. The distinction between ‘cortical’ and ‘subcortical’
dysphagia and personality change in the frontal lobe dementias can be helpfully refined by recognising that some
dementia linked with motor neuron disease.
Where an atypical cause is suspected, but its nature is Table 13.3 Delirium versus dementia
unclear, a range of further tests is worth considering (Box 13.6). Feature Delirium Dementia
Diagnosis Onset Acute or subacute Insidious
It is helpful to bear in mind two major distinctions during Course Fluctuating Slowly progressive
the clinical assessment of patients with possible dementia.
The first is the distinction between delirium (or ‘confusion’) Duration Hours–weeks Months–years
Box 13.6 Alertness Abnormally low Typically normal
or high
Additional investigations which may be helpful
in atypical dementia Sleep–wake Disrupted Typically normal
cycle
• Formal psychometric assessment
• Neuroimaging: MRI, SPECT Attention Impaired Relatively normal
• Other imaging: e.g. CXR
• Specialised blood tests, e.g. Orientation Impaired Intact in early dementia
—Genetic testing, e.g. Huntington’s, CADASIL, mitochondrial Working (ST) Impaired Intact in early dementia
disorders, familial AD, familial prion dementia memory
—White-cell enzyme studies in leucodystrophy Episodic (LT) Impaired Impaired
—HIV test memory
—Connective tissue serology in suspected CNS inflammation,
Thinking Disorganised, Impoverished
e.g. ESR, antinuclear factor (ANF), anticardiolipin antibodies, delusional
antineutrophil cytoplasmic antibodies (ANCA), antibodies to
extractable nuclear antigens (ENA), rheumatoid factors, Speech Slow or rapid, Word-finding difficulty
complement fractions incoherent
—Antithyroid antibodies in suspected Hashimoto’s
encephalopathy Perception Illusions, Typically unimpaired in early
—Caeruloplasmin in suspected Wilson’s disease hallucinations dementia (LBD is an exception)
• EEG common
• CSF examination
• Brain biopsy Behaviour Withdrawn or Varies with type of dementia but
agitated often intact in early stages
CADASIL, cerebral autosomal-dominant arteriopathy with subcortical infarcts and
leucoencephalopathy. LBD, Lewy body disease; LT, long-term; ST, short-term.
After Hodges (1994).
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Organic disorders CHAPTER 13
Table 13.4 Cortical and subcortical dementia attention, executive function, speed of processing, and
memory. Psychiatric symptoms and behavioural change are
Function Cortical dementia, Subcortical dementia, common: depression, apathy and aggressivity occur very com-
monly, with psychosis, obsessional behaviour and suicide in a
e.g. Alzheimer’s disease e.g. Huntington’s disease significant minority. Progression to a state of immobility and
dementia typically occurs over 15–20 years. Cognitive and
Alertness Normal ‘Slowed up’ behavioural change may predate the clear-cut emergence of
Impaired more obvious symptoms.
Attention Normal in early stages Impaired
Pathology and aetiology
Executive Normal in early stages Forgetfulness (improves with
function cueing) The epicentre of the pathology lies in the striatum, the caudate
Normal except for reduced and putamen. The loss of small neurons in the striatum is
Episodic (LT) Amnesia output accompanied by loss of neurons in the cerebral cortex, cerebral
memory Normal atrophy, ventricular dilatation and, eventually, neuronal deple-
Impaired tion throughout the basal ganglia. The underlying genetic abnor-
Language Aphasic features mality is expansion of a ‘base triplet repeat’ within the
Apathetic, inert Huntingtin gene. The function of Huntingtin remains uncertain.
Praxis Apraxia
Investigation and differential diagnosis
Perception, Impaired
visuospatial A number of disorders can cause a combination of chorea and
abilities cognitive change, including other inherited disorders such as
neuroacanthocytosis and dentato-rubro-pallido-luysian atrophy
Personality Preserved (unless frontal (DRPLA), and acquired disorders such as systemic lupus
type) erythematosus (SLE). The diagnosis can now be made with
confidence by DNA analysis. Counselling by a clinical geneti-
After Hodges (1994). cist is mandatory before presymptomatic testing and should
also be considered in other circumstances.
‘cortico-subcortical’ disorders combine features of both (for
example, Lewy body dementia and prion dementia). Box 13.7 Management
lists causes of dementia.
Patients may seek treatment for the chorea but this is usually
Inherited dementias best avoided, given the psychological and extrapyramidal
side-effects of the agents required – antipsychotics, dopamine-
Huntington’s disease depletors such as tetrabenazine, or benzodiazepines. Other
psychological and behavioural symptoms should be treated in
Definition the usual way.
Huntington’s disease (HD), also known as Huntington’s Wilson’s disease (hepatolenticular degeneration)
chorea, was first described in Long Island in 1872 by George
Huntington. This dominantly inherited disorder, which causes Definition
a combination of progressive motor, cognitive, psychiatric and
behavioural dysfunction, results from an abnormality in the First described by Wilson in 1912, Wilson’s disease is an
IT-15 gene on chromosome 4 encoding the protein Huntingtin. autosomal-recessive, progressive but eminently treatable disorder
of copper metabolism, causing personality change, cognitive
Epidemiology decline, an extrapyramidal disorder and cirrhosis of the liver.
Huntington’s disease occurs with a prevalence of approxi- Epidemiology
mately 6 per 100 000, with wide regional variation. The sexes
are affected equally. Onset can occur at any age, but most Wilson’s disease is rare, with a prevalence of 1 in 30 000 live
commonly in young or middle adulthood. The disorder exhi- births, and is distributed worldwide. Because there is a high
bits ‘anticipation’, that is the age of onset tends to decrease mortality associated with failure to diagnose the disease the
through the generations, especially with paternal transmission point prevalence is lower than frequency at birth.
(see below).
Clinical features
Clinical features
The onset of Wilson’s disease is most common in childhood or
Chorea, involuntary fidgety movements of the face and limbs, adolescence but can be as late as the fifth decade. It can pres-
is the characteristic motor disorder. As the disease progresses, ent to psychiatrists with personality change, behavioural distur-
other extrapyramidal features, including rigidity, dystonia bance, including psychosis, or dementia, and to neurologists
and bradykinesia, can develop, with associated dysphagia, dys- with a variety of extrapyramidal features, including tremor,
arthria and pyramidal signs. Epilepsy can occur. Cognitive dysarthria and drooling, rigidity, bradykinesia and dystonia.
dysfunction goes hand in hand with the motor disorder. The In virtually all symptomatic cases, there are ‘Kayser–Fleischer
dementia is predominantly ‘subcortical’, with impairment of rings’, rings of greenish-brown copper pigment at the edge of
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Companion to Psychiatric Studies
Box 13.7
Causes of dementia —Multiple sclerosis
—Vasculitis
Inherited —Hashimoto’s encephalopathy
• Huntington’s disease • Neoplastic
• Wilson’s disease —Primary and metastatic CNS tumours
• Leucodystrophies —Paraneoplastic: limbic encephalitis
• Traumatic
Acquired —Post head-injury
• Primary degenerative dementias • Structural
—Hydrocephalus
—Alzheimer’s disease —Chronic subdurals
—Dementia with Lewy bodies • Metabolic/endocrine
—Frontotemporal lobar degeneration (including Pick’s disease) —Hypothyroidism
—Progressive supranuclear palsy • Deficiency disorders
—Corticobasal degeneration —Vitamin B12/folate deficiency
• Vascular dementia • Sleep-related
—Multi-infarct —Obstructive sleep apnoea
—Subcortical • Substance-induced
—Strategic infarction —Alcohol
• Infective —Anticholinergics, antiepileptics, neuroleptics,
—HIV
—Transmissible spongiform encephalopathies (prion dementias) hypnotics, etc.
—Herpes simplex encephalitis • Psychiatric
—Whipple’s disease
—SSPE —Depression (‘pseudodementia’)
• Inflammatory
SSPE, subacute sclerosing panencephalitis.
NB: This simple classification of the causes of dementia is for dementia defined as significant cognitive impairment affecting more than one cognitive domain, which is not
primarily due to delirium. The list is not comprehensive, but the great majority of the causes of dementia fall under the categories listed. All dementias can be palliated; this
list also includes causes which are potentially reversible, for example hydrocephalus, Wilson’s disease and sleep apnoea. Rarely, some of the ‘acquired’ dementias listed
here can be inherited (e.g. dominantly inherited Alzheimer’s disease, inherited frontotemporal dementia and some prionopathies; see text).
the cornea (in suspected cases an ophthalmologist should be Management
asked to look for this with a slit lamp). Liver failure and the
psychiatric symptoms can occur together or independently. Copper-chelating agents are effective but carry a risk of sig-
nificant side-effects. Penicillamine is currently the most
Pathology and aetiology widely used agent; alternatives include tetraethylene tetramine
(trientine) and zinc acetate.
The causative mutation is in the copper-transporting P-type
ATPase coded on chromosome 13. The result is excessive cop- Leucodystrophies
per deposition in brain, cornea, liver and kidneys and increased
copper excretion in urine. The globus pallidus and putamen Leucodystrophies, recessively inherited or X-linked disorders
(together known as the lenticular nucleus) are most severely of myelination, can present with psychiatric symptoms, usually
affected, but the other basal ganglia and the cerebral cortex with associated neurological symptoms.
are also involved.
Investigation and differential diagnosis Degenerative dementias
Almost all patients have low levels of the copper-binding pro- Frontotemporal lobar degeneration (including
tein, caeruloplasmin, in the serum. A normal caeruloplasmin Pick’s disease)
and the absence of Kayser–Fleischer rings render the diagnosis
very unlikely. Difficult cases may require measurement of uri- Definition
nary copper excretion, and liver biopsy for measurement of
copper content. The differential diagnosis varies with the type This group of disorders is of importance to psychiatrists, as
of presentation. The combination of psychological disturbance personality change and behavioural disturbance may be the
and unusual neurological features has led to misdiagnosis as presenting features. The frontotemporal dementias (FTDs)
conversion disorder. are a clinically and pathologically diverse group of focal
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Organic disorders CHAPTER 13
dementias presenting with either features of frontal lobe Investigation and differential diagnosis
dysfunction or features of temporal lobe dysfunction or both.
Neuropsychological examination is particularly helpful in
Epidemiology identifying these clinical syndromes. Imaging should reveal
corresponding focal atrophy. A younger person presenting
Although a rare cause of dementia overall, frontotemporal with an atypical dementia requires a full neuropsychiatric
dementia (FTD) accounts for approximately 10–15% of cases assessment.
occurring before the age of 65. Some cases are familial.
Management
Clinical features
There is no proven specific treatment for these conditions (with
Dementia of ‘frontal type’, or ‘frontal variant FTD’, is charac- the possible exception of riluzole for motor neuron disease).
terised by the features listed in Box 13.8. The temporal lobe
variant presents most commonly with ‘semantic dementia’, Progressive supranuclear palsy
a syndrome of progressive word-finding difficulty, loss of
language comprehension, depletion of conceptual knowledge Progressive supranuclear palsy (PSP) is characterised by: a
(apparent on non-verbal as well as verbal tests) and impairment supranuclear gaze palsy (inability to direct eye movements
of object recognition. These features reflect left temporal lobe voluntarily, especially vertical eye movements, in the presence
dysfunction. If the right temporal lobe is more severely of normal reflex eye movements); truncal rigidity, akinesia,
affected, prosopagnosia (impaired face recognition) and loss of postural instability and early falls; and bulbar features, with
knowledge about people may be especially prominent. dysarthria and dysphagia; subcortical dementia and changes
in mood, personality and behaviour. Neurofibrillary tangles,
Pathology and aetiology consisting of tau protein, are found in neurons of the basal
ganglia and brainstem. Midbrain atrophy may be apparent
Several types of pathology can underlie the symptoms of FTD. on MRI.
The five principal types are:
• classical Pick’s disease pathology, with tau- and ubiquitin- Corticobasal degeneration
positive cortical inclusions (Pick bodies) and ballooned Corticobasal degeneration typically presents with a combi-
neurons; nation of limb apraxia, usually asymmetric at onset, alien limb
• neuronal loss with microvacuolation of outer cortical layers phenomena, limb myoclonus, parkinsonism and cognitive
and astrocytosis; decline. The pathology involves neuronal loss in both the basal
• tau-positive inclusions in neuronal and glial cells in familial ganglia and the frontal and parietal cortex, with intraneuronal
FTD with parkinsonism, linked to mutations in the tau gene accumulations of tau protein resembling those seen in PSP.
on chromosome 17; MRI usually reveals frontoparietal atrophy.
• motor neuron disease-type pathology; and
• corticobasal degeneration (CBD)-type pathology (see below). Infective dementias
The role of tau protein accumulation in Pick’s disease, inher-
ited FTD linked to chromosome 17, and CBD is a focus of Human immunodeficiency virus-1 (HIV-1) infection
current research.
Definition
Box 13.8
Human immunodeficiency virus-1 which causes the acquired
Criteria for a diagnosis of dementia of frontal type immunodeficiency syndrome, or AIDS, can cause a dementing
illness or HIV-1-associated dementia. This is the AIDS-
• Presentation with an insidious disorder of personality and defining illness in approximately 5% of patients with AIDS.
behaviour
Epidemiology
• The presence of two or more of the following features: loss
of insight, disinhibition, restlessness, distractibility, emotional About one-quarter of patients with AIDS will present with
lability, reduced empathy or unconcern for others, lack of or develop HIV-1-associated dementia. Dementia develops
foresight, poor planning or judgement, impulsivity, social within 2 years of the AIDS-defining illness in about half of
withdrawal, apathy or lack of spontaneity, poor self-care, these patients. Given the global prevalence of HIV-1 infection,
reduced verbal output, verbal stereotypes or echolalia, it is a major cause of dementia in young people worldwide.
perseveration, features of Kluver–Bucy syndrome (gluttony, pica,
sexual hyperactivity) Clinical features
• Relative preservation of day-to-day (episodic) memory The dementia is usually subcortical and presents insidiously.
• Psychiatric phenomena may be present (mood disorder, Difficulty with concentration, forgetfulness, cognitive slowing,
apathy and social withdrawal are early features. Global dementia
paranoia) eventually ensues. Neurological features, including pyramidal
• Absence of past history of head injury, stroke, alcohol abuse or and cerebellar signs, appear as the dementia progresses. A milder
disorder, HIV-1-associated minor cognitive/motor disorder,
major psychiatric illness which is not an AIDS-defining illness, is also recognised.
After Gregory & Hodges 1993.
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Companion to Psychiatric Studies
Pathology and aetiology Management
HIV-1 virus crosses the blood–brain barrier early in the course HIV is now a treatable, if not curable, cause of dementia. Com-
of infection, often at the time of the initial viraemia, and bined therapy with antiviral agents reduces the risk of progres-
persists within the CNS. The cells infected with HIV in the sing from HIV infection to AIDS and HIV-associated dementia.
CNS are predominantly macrophages and microglia; these
give rise to the microscopic hallmark of HIV dementia, Transmissible spongiform encephalopathies
the presence of multinucleated giant cells (MGCs). (prion dementias)
Investigation and differential diagnosis Definition
HIV testing, following appropriate counselling, should be con- The transmissible spongiform encephalopathies (TSEs) are a
sidered in patients with unexplained dementia, particularly group of rare dementias caused by an accumulation of abnor-
where the patient has risk factors for HIV infection (homo- mal prion protein within the brain. Related illnesses occur in
sexuality, unprotected sex with multiple partners, intravenous animals; indeed, one recently described disorder, variant
drug abuse, blood or blood product transfusions, etc.). MRI Creutzfeldt–Jakob disease (vCJD), is thought to result from
scanning typically reveals cerebral atrophy with regions of infection of humans by consumption of beef products from
increased T2 signal in the white matter and basal ganglia cattle with bovine spongiform encephalopathy (BSE). The
(Fig. 13.4). The CSF usually shows an increased cell count, term ‘prion’ stands for ‘proteinaceous infection pathogen’.
elevated protein and the presence of oligoclonal bands of
immunoglobulin. Epidemiology
There are causes of cognitive decline in patients with known All the TSEs are rare. Sporadic Creutzfeldt–Jakob disease
HIV infection besides HIV-associated dementia. These (spCJD), the most common human TSE, occurs with an
include the effects of depression, drugs and substance abuse, annual incidence of one per million population, usually affect-
systemic illness, opportunistic infections and HIV-related ing people between the ages of 55 and 70. Variant CJD has
tumours of the CNS, particularly lymphoma. Causes of CNS been diagnosed in approximately only 150 individuals at
infection to consider in this context include toxoplasmosis, the time of writing, almost all resident in the UK. It usually
tuberculosis, cryptococcosis, cytomegalovirus (CMV), syphilis develops in younger subjects than spCJD, and most cases have
and progressive multifocal leucoencephalopathy (PML). presented in the second to fourth decades of life.
Clinical features
Sporadic CJD typically causes a rapidly progressive dementia,
with early changes in behaviour, visual symptoms and cere-
bellar signs. Within weeks to months, marked cognitive
impairment develops, often progressing to mutism, with pyra-
midal, extrapyramidal and cerebellar signs and myoclonus.
The median duration of symptoms to death is only 4 months.
Iatrogenic cases of CJD (iatCJD) have occurred when CNS
tissue from patients with spCJD has unwittingly been trans-
ferred from patient to patient by surgical instruments, or
used in medical procedures as a source of growth hormone,
gonadotropins, dura mater or corneal grafts.
Variant CJD differs markedly from spCJD. The initial
symptoms are usually psychiatric — in particular anxiety or
depression — often sufficiently severe to lead to psychiatric
referral (Spencer et al 2002). Limb pain or tingling is common
early in the course of the illness. After some months cognitive
symptoms typically develop, causing difficulty at school or
work, together with varied neurological features including
pyramidal, extrapyramidal and cerebellar signs and myoclonus.
The disorder evolves more slowly than spCJD, with an average
duration to death of 14 months.
Fig. 13.4 MRI scans in HIV-1 dementia typically reveal cerebral Pathology and aetiology
atrophy with regions of increased signal in the white matter and basal
ganglia. The light microscope reveals ‘spongiform change’ in the brain
associated with neuronal loss, gliosis and deposition of ‘amy-
loid’. Immunocytochemistry and direct biochemical analysis
indicate that the amyloid is composed of a protease-resistant
form of prion protein (PrP). PrP is a membrane-associated
neuronal protein coded on the short arm of chromosome 20.
In TSEs, PrP is thought to undergo a conformational change
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Organic disorders CHAPTER 13
to a disease-associated form, PrPsc, which both renders PrP Edinburgh, can mobilise the substantial package of support
resistant to normal degradation, and confers upon it the capac- which is now available for patients with CJD, and, in the inter-
ity to convert other molecules of PrP to PrPsc. This process of ests of accurate disease surveillance, it is vital that all cases
catalysis gradually results in the toxic accumulation of PrPsc. In should be reported to the Unit.
spCJD the initial conformational change occurs ‘spontane-
ously’; in transmitted cases it is catalysed by exogenous PrPsc; Other rare infective causes of dementia
and in inherited cases, a mutation in the PrP gene renders the
molecule more than usually vulnerable to spontaneous trans- Whipple’s disease
formation to PrPsc. This radical ‘prion hypothesis’ explains
how one and the same disorder can occur in sporadic, infective Whipple’s disease is rare but important because it is treatable.
and inherited forms (Aguzzi et al 2000). Infection with Tropheryma whippelii typically causes a multi-
system disorder with prominent steatorrhoea, weight loss
Investigation and differential diagnosis and abdominal pain. CNS involvement is common, and neuro-
logical symptoms and signs, psychiatric symptoms and demen-
In spCJD the EEG shows 1–2/second triphasic waves in tia can occur in the absence of systemic features. Antibiotic
80% of cases at some time during the course of the illness. treatment can be effective.
Detection of 14–3-3 protein in CSF has a sensitivity and spec-
ificity of 90% for spCJD. Brain biopsy is usually diagnostic but Subacute sclerosing panencephalitis
rarely performed. In vCJD the EEG and CSF examination are
less useful, but characteristic MRI abnormalities (especially Subacute sclerosing panencephalitis (SSPE) is a rare complica-
high signal in the pulvinar nucleus; see Fig. 13.5) are found tion of childhood measles, due to intraneuronal persistence of
in a high proportion of cases, giving a sensitivity of 78% and a defective form of the virus in the CNS causing a continuing
specificity of 100% in one study. Tonsillar biopsy has also been immune response with high levels of measles antibody in the
used as a confirmatory test that PrPsc is found in lymphoid tis- CSF. Neurological signs, including myoclonus, accompany the
sue in vCJD. In suspected cases of familial TSE, sequencing of dementia. Average life expectancy from onset is 1–2 years.
the PrP gene will identify the causative mutation.
Progressive multifocal leucoencephalopathy
Management
Progressive multifocal leucoencephalopathy (PML) is caused
At present, there is no proven remedy for prion-associated dis- by activation of JC Papova virus within the CNS in an immu-
ease. In the UK the CJD Surveillance Unit, based in nocompromised patient. The resulting demyelination gives
rise to pyramidal signs, visual impairment and a subcortical
dementia usually progressing to death over months.
Herpes encephalitis
Herpes encephalitis, which spreads through limbic pathways,
can leave dementia in its wake if treatment of the acute
encephalitis is unsuccessful or delayed.
Fig. 13.5 MRI scans in vCJD are characterised by high signal Inflammatory dementias
intensity in the pulvinar nucleus.
A number of inflammatory conditions affecting the CNS can
cause dementia. The diagnosis will generally be suggested by
the presence of features that are atypical for other common
causes. These may be systemic, such as the butterfly rash,
arthralgia and renal impairment often associated with systemic
lupus erythematosus, or the oral and genital ulcers and iritis
of Beh¸cet’s syndrome, or neurological, such as the headache
and fluctuating confusion of cerebral vasculitis, or the upper
motor neuron signs which usually occur in multiple sclerosis.
Features likes these – or unexplained dementia in a younger
person – call for ‘additional investigations’ listed in Box 13.6,
in particular serological tests for inflammatory disorders,
neuroimaging with MRI and CSF examination.
Multiple sclerosis
A demyelinating disorder of the central nervous system, MS
causes some degree of cognitive impairment in almost half of
cases and can present with unexplained subcortical dementia.
The disorder can also cause and occasionally present with
affective disorders. The presence of high signal abnormalities
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Companion to Psychiatric Studies
on T2-weighted MRI, and of oligoclonal bands of immunoglob- encephalitis’ is more challenging. This disorder results from
ulin in the CSF, help to confirm the diagnosis. immunological cross reaction between tumour antigens and
antigens present within the CNS. It can give rise to a range
Systemic lupus erythematosus of presentations, including confusional states, a pure amnesic
syndrome and affective symptoms. Small-cell lung cancer is
Systemic lupus erythematosus is a multisystem inflammatory the most common cause, but breast cancer, gynaecological
disorder which can be accompanied by CNS involvement. tumours, renal carcinoma, testicular tumours and lymphoma
The mechanisms are vascular and immunological, with psy- can also be responsible. The tumour may be small and some-
chiatric and cognitive symptoms sometimes amounting to times undetectable by imaging initially. The diagnosis is sup-
delirium or dementia. Serological tests for antibodies includ- ported by the detection of antineuronal antibodies in serum
ing antinuclear factor, DNA-binding and anticardiolipin are or CSF, most commonly ‘anti-Hu’; the CSF often contains
helpful. Immunosuppression is indicated in ‘cerebral lupus’. oligoclonal bands of immunoglobulin.
Cerebral vasculitis Traumatic dementias
Inflammation of blood vessels within the CNS (cerebral vascu- Trauma is one of the few causes of abrupt-onset dementia and
litis) can occur in association with several systemic vasculitic is discussed further under traumatic brain injury.
disorders, such as polyarteritis nodosa, Wegener’s polyarteritis
and Churg–Strauss syndrome, or as an isolated process Structural dementias
(‘isolated angiitis of the CNS’). It can present with headache
and confusion, often accompanied by neurological signs and Hydrocephalus
sometimes seizures. If untreated, dementia may result. Immu-
nosuppression can be effective, but brain biopsy is usually Definition
required for a confident diagnosis.
Hydrocephalus (HC) is dilatation of the ventricles within
Hashimoto’s encephalopathy the brain caused by elevation of the pressure of the CSF
synthesised within them. It is ‘communicating’ when the
This is a recently recognised disorder associated with high block to CSF flow occurs outside the ventricular system and
titres of antithyroid antibodies causing either a progressive non-communicating when the block is within the ventricles
dementia, often with psychotic features, or a more acute ill- (for example in the narrow aqueduct of Sylvius, a common
ness with stroke-like episodes, confusion and seizures. The site of obstruction to CSF flow). In ‘compensated’ hydro-
diagnosis should be suspected in patients with known autoim- cephalus, the clinical signs and CSF dynamics stabilise at an
mune thyroid disease and unexplained cognitive impairment, elevated level of CSF pressure. In ‘normal pressure hydro-
and in patients with unexplained atypical dementia. cephalus’, the ventricles enlarge despite apparently normal
CSF pressure, possibly as a result of intermittent surges of
Limbic encephalitis high pressure.
Limbic encephalitis is a form of non-infective inflammation Clinical features
centred on the limbic system, presenting with some combina-
tion of seizures, often complex partial, memory impairment, Hydrocephalus can cause a wide range of neurological and psy-
confusion and alterations of mood, personality and behaviour. chiatric symptoms and signs. Manifestations include enlarge-
Previously associated with cancer (see below), recent evidence ment of the head (if present in infancy), headache, sudden
suggests that limbic encephalitis in fact more often occurs death due to ‘hydrocephalic attacks’ with acute elevation of
independently of cancer, as an autoimmune phenomenon intracranial pressure, progressive visual failure, gait disturbance
(Vincent et al 2004). Antibodies to voltage-gated potassium (often ‘gait apraxia’), incontinence and subcortical cognitive
channels are often present, and are useful diagnostically. Other impairment progressing to dementia. ‘Normal pressure hydro-
clues to the diagnosis include hyponatraemia and the presence cephalus’ in older people is classically associated with the triad
of signal change in the medial temporal lobes. Some patients of gait apraxia, incontinence and cognitive decline.
improve markedly with immunosuppressive treatment.
Investigation and differential diagnosis
Neoplastic dementias
In a younger person the radiological signs of hydrocephalus are
CNS tumours usually clear-cut on CT scanning. This is sometimes true in the
elderly, but in other older patients an apparent hydrocephalus
While primary and metastatic CNS tumours typically present is sometimes due to atrophy of the brain rather than to dilata-
with headache, focal neurological signs or seizures, they can tion of the ventricles. When enlargement of the ventricles
also cause cognitive impairment and occasionally mimic a raises a suspicion of communicating hydrocephalus in an older
dementing illness. CT scanning should reveal their presence, person, specialised studies are required to determine whether
although diffusely infiltrating tumours are occasionally missed the scan appearance is relevant to the clinical problem (usually
in the early stages. The diagnosis of paraneoplastic ‘limbic either serial lumbar punctures with observation of the clinical
effects, or neurosurgical CSF pressure studies).
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Organic disorders CHAPTER 13
Management
The insertion of a ‘shunt’ that allows the diversion of CSF
from the CSF space to venous system or peritoneum can be
beneficial or even life-saving. However, it is prone to complica-
tions, including subdural haematomas and infection and should
not be undertaken lightly.
Subdural haematoma
Definition
Subdural haematomas are accumulations of blood and blood
products in the space between the fibrous dura mater and
the more delicate arachnoid membrane which encloses the
brain. Acute subdural haematomas accumulate rapidly follow-
ing head injury; chronic subdural haematomas can sometimes,
but not always, be traced back to a head injury.
Clinical features Fig. 13.6 CT scan of large subdural haematoma showing
compression of the ventricles and midline shift.
Acute subdural haematomas are, by definition, diagnosed close
to the time of trauma, as a result either of symptoms present treated. The early cognitive symptoms are usually mental leth-
at the time – headache, depressed level of consciousness, focal argy and slowing of cognition. A wide range of physical symp-
neurological signs – or from a CT scan. Chronic subdurals give toms, apathy, depression, confusion or psychosis (‘myxoedema
rise to more gradually evolving symptoms and signs. While madness’), may also occur.
they, also, can cause headache, depressed consciousness and
focal signs, they sometimes result in predominantly cognitive Deficiency disorders
features, including confusion and dementia. Marked variability
of the mental state, and sometimes also of the neurological Vitamin deficiency
features, is often a clue to the diagnosis. Seizures can occur.
Deficiency of B vitamins, especially B1 (thiamine) and B12
Pathology (cobalamin compounds), and of folic acid are important causes
of organic psychiatric disorders. B1 (thiamine) deficiency,
The variability of the clinical features is explained by the ten- causing Wernicke’s encephalopathy in the acute phase, and
dency of the size of chronic subdurals to wax and wane as a Korsakoff’s psychosis if untreated, is discussed under amnestic
result of alternating phases of bleeding and of breakdown of syndromes. Vitamin B12 and folate deficiency are relatively
the contents of the chronic haematoma. rare but highly treatable causes of dementia, and the concen-
tration of these vitamins in the blood should be checked in
Investigation and differential diagnosis patients with cognitive decline.
Subdural haematomas can generally be diagnosed on CT scan- Sleep-related dementias
ning (Fig. 13.6). They are occasionally ‘isodense’ with brain
and therefore easily missed, especially if bilateral. It is impor-
tant to recognise that a small subdural can be an incidental
finding: cerebral atrophy occurring in the course of a dement-
ing illness, for example, predisposes to subdural haematoma
as vulnerable bridging veins are stretched between the dura
and the arachnoid. In these circumstances treatment of the
subdural is unlikely to be helpful.
Management
This requires liaison with a neurosurgical team. Small subdural
haematomas often resorb spontaneously. If a subdural is con-
sidered to be relevant to a patient’s problems, and drainage is
required, several surgical approaches are available.
Metabolic and endocrine dementias Obstructive sleep apnoea
Hypothyroidism Obstructive sleep apnoea typically presents with excessive
daytime sleepiness (EDS) on a background of snoring and
Thyroid function tests should always be performed in patients intermittent apnoea due to upper airways obstruction in sleep,
with cognitive decline, as hypothyroidism can present with most often in obese middle-aged men. The patient is often
cognitive symptoms, progressing to dementia, and is readily unaware of the extent of his sleep disturbance, and present
333
Companion to Psychiatric Studies
with non-specific symptoms such as fatigue, forgetfulness or sadness, an organic cause, such as a subcortical dementia,
impaired concentration. might well be considered. On cognitive examination, depres-
sive pseudodementia is likely to produce slowed responses,
Substance-induced dementias paucity of speech and impaired concentration in the absence
of ‘cortical’ deficits such as dysphasia or agnosia.
Alcohol and recreational drugs
Hysterical pseudodementia is suggested by unexpectedly
The question of whether excessive alcohol intake alone severe and inconsistent impairment of cognitive function,
damages the brain — as opposed to the associated thiamine especially in the context of other ‘functional’ symptoms
deficiency, head injury, secondary hypoglycaemia and other and signs. Some cases occur on a background of dramatic
consequences — has been much debated. The balance of psychological precipitants.
evidence suggests that alcohol itself can cause cognitive
impairment and cerebral atrophy, although its effects are often Aetiology
compounded by additional factors. Chronic misuse of other
substances and its complications can cause or contribute to A number of cognitive mechanisms, including a tendency to
cognitive decline. It is important therefore to take a history retrieve distressing memories, and an over-general retrieval
of recreational drug use, including alcohol, in patients with style, help to explain the cognitive deficits associated with
cognitive symptoms. depression. There is also recent evidence, from a combination
of animal and human studies, that both depression and stress
Medication-induced dementias affect structure and function in the hippocampus by modula-
tion of circulating glucocorticoids, mineralocorticoids and
Occasionally, prescribed medication causes or contributes to monoaminergic inputs.
cognitive impairment. Drugs which can be responsible include
anticholinergics, anticonvulsants (especially barbiturates), Investigation and differential diagnosis
hypnotics and neuroleptics.
The most commonly encountered clinical dilemma is the dis-
Functional psychiatric disorders that can tinction between a primary depressive illness causing cognitive
mimic dementia impairment and an organic dementia with associated mood dis-
turbance. The diagnoses of dementia and depression are not, of
Depressive, hysterical and simulated course, mutually exclusive. Features which may point towards
‘pseudodementia’ and the Ganser syndrome depression being the primary process include the recent occur-
rence of negative life events, a relatively abrupt onset and varia-
Definition bility of cognitive dysfunction. Psychometric testing can be
helpful but sometimes it is only possible to reach a definite con-
In ‘pseudodementia’, which is a functional psychiatric disorder clusion in retrospect, after conducting an adequate trial of treat-
or rarely a deliberate simulation, the clinical picture is similar ment for depression and allowing the passage of time.
to that of an organic dementia. However, there are differences
which aid in differential diagnosis: Management
• Depressive pseudodementia is cognitive impairment on the
Depression should be treated in the usual way. There is little
background of a depressive illness, sometimes in the evidence to guide our management of ‘hysterical pseudo-
absence of typical symptoms of depression. dementia’, but the generally agreed approach is strong reassur-
• Hysterical pseudodementia is cognitive impairment ance that the disorder will improve, followed by rehabilitation.
mimicking organic dementia which proves not to be due to ‘Abreaction’ (interviewing under light sedation with diazepam
organic pathology. ‘Functional dementia’ might be a more or sodium amytal) has sometimes been used to good effect as a
appropriate term for both depressive and hysterical diagnostic and therapeutic tool, as it may alleviate functional
pseudodementia. impairment, but is likely to exacerbate most types of organic
• Simulated dementia is cognitive impairment that has been cognitive impairment.
feigned deliberately in the pursuit of some form of gain.
Delirium
Clinical features
Delirium is a syndrome characterised by concurrent distur-
Depression is the most common potentially reversible cause bances of consciousness and attention, perception, cognition,
of cognitive impairment encountered in memory clinics. behaviour, emotion and the sleep/wake cycle. It is aetiologi-
Where cognitive impairment occurs in someone who is overtly cally non-specific and not infrequently there a re multiple
depressed, the diagnosis will be immediately suspected. underlying aetiological factors. Delirium has also been
But when loss of interest in the environment is coupled with described using other terms including ‘acute confusional state’,
slowing of thought and behaviour, in the absence of overt ‘acute brain syndrome’ and ‘acute organic reaction’.
Epidemiology
Delirium is extremely common in day to day clinical practice
particularly within services providing care for older people
334
Organic disorders CHAPTER 13
(increasingly this includes medical admissions units), surgical of delirium often have a more severe underlying illness and
wards, oncology wards and intensive care units. Most preva- worse prognosis (O’Keefe & Lavan 1999).
lence studies have been carried out in hospitalised medically
ill patients. The prevalence of delirium rises with age and is The inability of patients with delirium to focus and sustain
also greater in the terminally ill and in certain groups of post- attention is of particular clinical importance and highly
operative patients, e.g. following hip fracture surgery, trans- relevant in management. Failure to recognise this sometimes
plant surgery and burns. Table 13.5 illustrates the prevalence results in aggressive incidents which could be find e.g. simple
of delirium in different patient populations. routine procedures such as blood tests and physical examina-
tions may need to be explained on more than one occasion if
Clinical features they are not to be misperceived as assault and result in an
aggressive response from patients. Memory impairment in
There are four cardinal clinical features of delirium (DSM-IV): delirium reflects lack of attention, and if attention can be
sustained retrograde memory will often be intact. However,
• disturbance of consciousness with reduced ability to focus, more often there is a dense amnesia with islands of memory
sustain or shift attention; during periods of lucidity. Disorientation for time and place
is almost universal. Patients in hospital often believe they
• altered cognition or the development of a perceptual are in their own homes or in their places of work. Perceptual
disturbance; disturbances include hallucinations (often visual) and misin-
terpretations and delusions. Visual hallucinations are often
• the disturbance develops over a short period of time and is vivid and frightening. Delusions are very common as are
fluctuating; and perceptual distortions including micropsia and macropsia.
Delusions are usually fleeting and transitory and may result
• history, examination and laboratory investigation reveal from misinterpretations, e.g. a patient may see a nurse add
delirium to be a physiological consequence of an underlying sugar to their tea and develop the belief they are being poi-
general condition or to being caused by intoxication or soned. Patients lack the ability to think coherently with
medication or by more than one of these aetiologies. marked disorganisation and poor direction of thought. This
results in difficulties with planning even the simplest of
The neuropsychological hallmark of delirium is marked actions.
abnormalities of attention. This is often accompanied by a gen-
eralised cognitive impairment affecting orientation, memory Disturbance of the sleep–wake cycle is almost invariable
and planning skills. A fluctuating level of consciousness and with reversal of the normal cycle being usual. Patients are
awareness of the surrounding environment is almost invariable. usually at their most agitated during the night. Sleep is often
Accompanying disturbances of the sleep–wake cycle, affect, disturbed by frightening nightmares which can merge
perception and psychomotor performance are also highly clin- imperceptibly with the hallucinations the patient has on wak-
ically relevant both in terms of diagnosis and management. The ening. The importance of abnormalities of mood in patients
symptoms of delirium are usually worse at night. with delirium is underrecognised. This is particularly the
case with anxiety and fearfulness which again can result in
Three clinical variants of delirium have been described aggressive incidents. As with other features of the disorder
(Lipowski 1989): mood may fluctuate rapidly from one emotional state to
another.
• a hyperalert-hyperactive type;
• a hypoalert-hypoactive type; and Diagnosis and differential diagnosis
• a mixed type.
Surveys show that delirium is not recognised in as many as
The hypoalert-hypoactive form of delirium is frequently 50% of patients who suffer from it (Meagher 2001). Failure
under-recognised and sometimes even misdiagnosed as depres- to diagnose delirium is important as it is associated with a
sion. This is particularly important as patients with this variant worse prognosis and even death due to failure to recognise
and treat serious underlying medical causes. Accidental injury
Table 13.5 Incidence and prevalence of delirium from associated behavioural disturbance including wandering
Percentage with delirium and falls is also important. McCusker et al (2003) have
demonstrated that patients with delirium have increased mor-
Hip fracture – post op >60 40–55 (incidence) tality, increased length of stay and worse physical and cognitive
recovery at 1 year. This again underpins the importance of
General medical >65 20% within 1 week (prevalence) prompt recognition and treatment.
Accident and Emergency 10 (prevalence) With regard to diagnosis of delirium this is essentially clini-
cal and based on recognition of the key clinical features above,
ICU >65 70 particularly the four core features (see Box 13.9).
Old age wards 50 (during their stay) With regard to differential diagnosis the most important
distinction is between delirium and dementia. This is usually
All hospital admissions 10–15 clarified by obtaining a good third party history from relatives
Prevalence figures from Clinical Practice Guidelines for the Management of Delirium
in Older People in Australia. Australian Journal of Ageing, 27, 3, 150-156 (2008).
335
Companion to Psychiatric Studies
Box 13.9 dissociative disorders tends to be circumscribed (e.g. to past
personal memories) and does not correspond with accepted
Risk factors for delirium patterns.
Patient factors Pathogenesis and etiology
Individual: Although as stated the diagnosis of delirium is essentially clin-
• Age ical it is likely that case ascertainment could be improved by
• Pre-existing cognitive deficit using a number of aids to diagnosis particularly in elderly
• Severe comorbidity populations. The British Geriatrics Society guidelines (Guide-
• Previous episode of delirium line for the Presentation, Diagnosis and Management of Delir-
• Personality before illness ium in Older People in Hospital January 2006) recommend
the following:
Perioperative:
• Course of postoperative period • All elderly patients admitted to hospital should have
• Type of operation (for example, hip replacement) cognitive testing, e.g. using screening tools such as the
• Emergency operation abbreviated mental test (AMT) and mini mental state
• Duration of operation examination (MMSE).
Specific conditions: burns; AIDS; fracture; hypoxaemia; organ
• Serial measurements in at risk patients may detect a new
insufficiency; infection; metabolic disturbances (for example, development of delirium and its resolution.
dehydration, low serum albumin concentration)
• Third party history from a relative or carer is essential to
Pharmacological factors help distinguish between delirium and dementia.
• Treatment with many drugs
• Dependence on drugs or alcohol • Diagnosis of delirium can be made by non psychiatrically
• Use of psychoactive drugs or alcohol trained clinicians quickly and accurately using the
Confusion Assessment Method (CAM; Inouye et al 1990)
Environmental factors screening instrument.
• Extremes in sensory experience (for example, hypothermia)
• Deficits in vision or hearing Pathogenesis
• Immobility or decreased activity
• Social isolation Hypotheses regarding the physiology of delirium are focussed
• Novel environment largely on the role of neurotransmitters (particularly but not
• Stress exclusively acetylcholine) and reduction in cerebral oxidative
metabolism. Immunological factors have also been thought to
and/or significant others. This being said there is a strong rela- have a possible role (Broadhurst & Wilson 2001).
tionship between delirium and dementia (Fick et al 2002).
Delirium is clearly associated with an increased risk of devel- Cholinergic pathways have been thought to be particularly
oping dementia and is also frequently superimposed on important. The cholinergic system is widely distributed
dementia which lowers the threshold for developing delirium. through the brain and is involved in vision, attention, memory
Particular difficulty is in distinguishing Lewy body dementia and sleep, all of which can be disturbed in delirium. The cho-
from delirium because of its fluctuant course, although the linergic deficiency hypothesis of delirium has recently been
presence of Parkinsonian symptoms and sensitivity to treat- reviewed (Hshieh et al 2008). Although undoubtedly impor-
ment with antipsychotic drugs may help discriminate Lewy tant cholinergic deficiency is not in itself a sufficient explana-
body dementia from delirium. tion for the pathophysiology of delirium and it is of interest
that despite promising evidence from open studies, a recent
There are occasional difficulties in distinguishing the Cochrane database systematic review (Overshott et al
hypoalert-hypoactive variant of delirium from depression but 2008) has concluded that as yet there is insufficient evidence
in the former sustained low mood and anhedonia is absent from randomised controlled trials to support the use of cho-
and fluctuating disorientation present. Antidepressants usually linesterase inhibitors in the treatment of delirium.
make the delirium worse.
The underlying causes of delirium include hypoxia, lack of
Sometimes florid psychotic symptoms in the hyperalert- glucose and amino acids, vitamin deficiency, deficient synthe-
hyperactive variant of delirium lead to a misdiagnosis of sis and blockade of neurotransmitters, accumulations of tox-
psychosis but again the marked fluctuating mental state and ins and false transmitters, impaired cerebral blood flow,
impairment of attention and memory and evidence for an increased permeability of the blood–brain barrier and damage
underlying cause usually makes the distinction fairly straight- to cell membranes. These cellular mechanisms are reflected
forward. in the risk factors for delirium, i.e. age, impaired cognitive
functioning, severe physical illness, use of alcohol and drugs,
Even more occasionally delirium may be confused with dehydration and infection, electrolyte disturbance and low
dissociative disorders. Both are often sudden in onset. In albumen.
the latter loss of personalised identity commonly occurs
whereas it does not in delirium. Also memory loss in Delirium is frequently due to multiple aetiologies and this
should be borne in mind when it is being investigated and
treated. The most common single cause particularly in the
elderly is intoxication due to prescribed drugs. Drugs with
336
Organic disorders CHAPTER 13
Box 13.10 sometimes in distinguishing delirium from dementia, depres-
sion or from non-convulsive status epilepticus. If these initial
Common medical causes of delirium investigations reveal no underlying cause occasionally further
investigations have to be carried out and more rare disorders
• Intoxication with drugs — many drugs implicated especially considered.
anticholinergic agents, anticonvulsants, anti-parkinsonism
agents, steroids, cimetidine, opiates, sedative hypnotics, also Management
alcohol and illicit drugs
There are four key aspects to the management of delirium:
• Withdrawal syndromes — alcohol, sedative hypnotics,
barbiturates • identifying and treating the underlying cause (or causes);
• paying attention to environmental and supportive measures
• Metabolic causes:
—hypoxia, hypoglycaemia, hepatic, renal or pulmonary including regular reality orientation;
insufficiency • pharmacological interventions; and
—endocrinopathies (such as hypothyroidism, hyperthyroidism, • regular review and follow-up.
hypopituitarism, hypoparathyroidism or hyperparathyroidism)
—disorders of fluid and electrolyte balance Identifying and treating the cause
—rare causes (such as porphyria, carcinoid syndrome)
This can sometimes be difficult especially when patients are
• Infections unable to give a coherent history or won’t cooperate with
• Head trauma examination or attempts to investigate them. Very occasionally
• Epilepsy — ictal, interictal, or postictal it is justifiable to judiciously sedate a patient to enable adequate
• Neoplastic disease physical examination and/or investigation to be conducted.
• Vascular disorders: When underlying causes are identified appropriate treatment
should be started without delay.
—Cerebrovascular (such as transient ischaemic attacks,
thrombosis, embolism, migraine) Environmental and supportive measures in delirium
—Cardiovascular (such as myocardial infarction, cardiac failure) One of the most important aspects of managing delirium is to
ensure that all members of the multidisciplinary team receive
anticholinergic activity are particularly likely to cause delir- adequate training in identification and management. The impor-
ium but in clinical practice any drug should be considered a tance of nursing in an appropriate sensory environment and
potential cause of delirium. The medical conditions which regular reality orientation cannot be underestimated. It has
precipitate delirium are listed in Box 13.10. even been suggested that this training is extended to non-
clinical members of staff who may have occasional interac-
Withdrawal from alcohol and sometimes from sedative tion with patients, e.g. ward clerical staff and those serving
hypnotic drugs is a common cause from delirium and should refreshments. Following the publication of the Yale delirium
be considered in patients who have recently been hospitalised prevention model of care (Inouye et al 1999) there has been
and separated from their supply. Delirium tremens, a form considerable interest in multidisciplinary and multifaceted
of delirium associated with alcohol withdrawal, is worthy of approaches to the prevention of delirium. There is now
special attention as it is so common and a major contributor evidence from one randomised control trial (Mercantonio
to causes of behavioural disturbance in acute medical and et al 2001) that such approaches are helpful. They are based
surgical environments. In delirium tremens anxiety and auto- on working with modifiable risk factors in individual patients
nomic overactivity are particularly prominent. There are often and the intervention initiated is complex and requires signif-
associated metabolic disturbances and withdrawal seizures icant training of multidisciplinary teams. The Yale group has
which complicates the management. translated this work into routine clinical practice using a
programme called Hospital Elder Life Programme (HELP)
Infections are also very common precipitants of delirium (Inouye et 2000). The evidence for these delirium preven-
and in the elderly even innocuous infections can precipitate tion approaches has recently been summarised in a Cochrane
delirium particularly in those who already have a degree of database systematic review (Siddiqi et al 2007).
cognitive impairment. Postoperative delirium is also very com-
mon in elderly surgical patients particularly in those taking These programmes include training staff in the use of reality
anticholinergic drugs or misusing alcohol. orientation, therapeutic activity, the importance of mobilisa-
tion, non-pharmacological approaches to managing sleep and
Investigations mood disturbance, optimising use of equipment for dealing
with visual and hearing impairment and optimising pain
These should be guided by the history (including third party management.
history) and as careful and full a physical examination as the
patient will permit. As a routine, full blood count, urea and Involving family and friends in assisting with orientating
electrolytes, blood sugar, blood gas analysis, C reactive protein, patients and helping them feed and comply with other
liver function test, thyroid function, calcium, urine analysis, aspects of management is very important. Optimising the
culture of midstream urine and chest X-ray should be carried environment is crucial. This includes ensuring adequate
out. Occasionally when the diagnosis is in doubt an electroen- lighting, limiting the number of attendants and judicious use
cephalogram will be helpful which shows diffuse background of clocks, calendars and objects familiar to the patient which
slow-wave activity in delirium. An EEG is also useful
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Companion to Psychiatric Studies
Box 13.11 Benzodiazepines are the preferred drugs when delirium is
associated with withdrawal from alcohol or sedatives and are
General management of delirium also sometimes used as alternatives or additives to antipsy-
chotics when these are ineffective or causing unacceptable
• Education of all who interact with patient (doctors, nurses, side-effects. They have the advantage that their effects can
ancillary and portering staff, friends, family) be rapidly reversed with flumazenil. Lorezepam is often the
drug of choice as it has a relatively short duration of action,
• Reality orientation techniques: has no active metabolites and can be given intramuscularly.
—firm clear communication, preferably by same member of staff It is certainly safer when there are any concerns about hepatic
—use of clocks and calendars function. Again it is important that the dose is given regularly
and that a gradual reduction takes place over about 5–6 days.
• Creating an environment that optimises stimulation (adequate In recent years there has been a trend towards using so-called
lighting, reducing unnecessary noise, mobilising patient atypical antipsychotics, e.g. olanzapine and risperidone, as it
whenever possible) was claimed they have the advantage of having fewer extrapy-
ramidal side-effects. The wisdom of this strategy has been
• Correcting sensory impairments (providing hearing aids, glasses, thrown into doubt by recent research demonstrating increased
etc.) risk of stroke in patients receiving antipsychotic drugs. These
concerns first arose when a pharmaceutical company (Janssen,
• Ensuring adequate warmth and nutrition the manufacturer of risperidone) issued a warning highlighting
• Making environment safe (removing objects with which patient a possible association between prescription of risperidone and
stroke. In 2004 the Committee of Safety of Medicines in the
could harm self or others) UK recommended avoiding atypical antipsychotic drugs in
patients with dementia. Most studies which have investigated
may assist orientation. The safety of the environment should this have demonstrated an increased risk of stroke in patients
also be considered; objects the patient may use to injure him- receiving antipsychotic drugs (Douglas & Smeeth 2008;
self or others should where feasible be removed. Attending to Sacchetti et al 2008). In the largest and best of these studies
nutrition, hydration and toileting needs should not be forgot- (Sacchetti et al 2008) the risk was shown to be highest for
ten (Box 13.11). first-generation antipsychotics (especially phenothiazines).
Current best practice would be to advise extreme caution in
Pharmacological management using any antipsychotic drugs in patients with risk factors for
stroke and as this obviously includes many patients with delir-
The most important principle to be observed in the pharma- ium it makes the pharmacological management of delirium
cological management of delirium is that the use of sedatives even more of a difficult and vexatious issue than it was before.
and major tranquilisers should be kept to a minimum and It is still accepted that there are circumstances when these
used very judiciously. It should be borne in mind that all of drugs will have to be given in the interests of the patient’s
these drugs have the potential to cause delirium directly. In health and/or safety. Best practice in these situations would
addition sedating drugs may exacerbate underlying causes of be to document an awareness of the risk and discuss risk with
delirium, precipitate falls and worsen cognitive impairment. relatives and carers of patients.
Doctors should resist pressure from others including medical
colleagues, nurses and relatives to sedate people inappropri- Regular review
ately. When drugs do need to be used the aim is usually to
sedate or treat psychotic symptoms. There are few rando- A common shortcoming in the management of delirium is
mised controlled trials in drugs in delirium for rather obvious failure to review the patient on a regular basis. This often
reasons, but one (Breitbart et al 1996) has demonstrated the results in people being seen as an emergency in ‘out of hours’
superiority of high-potency antipsychotic drugs over benzo- situations and inadequately reviewed the following day
diazepines. Nearly all existing guidelines (e.g. British Geriat- because the doctor who first saw them is no longer in the hos-
ric Society) recommend haloperidol as the drug of first pital. It is essential that systems of care are in place to ensure
choice for delirium other than that caused by withdrawal patients with delirium are reviewed at a minimum on a daily
from alcohol or benzodiazepines. Usually doses of between basis thereafter for the duration of their hospital stay. It is par-
1 mg and 10 mg per day are adequate for most patients and ticularly important that any drugs used to treat delirium are
can be administered intramuscularly if required. The dose used in as small a dose as possible and for as short a time as
in the elderly should be low with starting doses of 0.5 mg b. possible and stopped as soon as is feasible.
d. advised. It is preferable to use a fixed dosing regime and
the regime should be reviewed at a minimum at least every Visual hallucinations
24 hours with patients being monitored regularly for both
response and emergency of side-effects. Particularly trouble- Delirium and substance intoxication/withdrawal account for
some side-effects include sedation, extrapyramidal and antia- the vast majority of patients presenting with visual hallucina-
drenergic effects, in particular hypotension. Some authorities tions. However, there are a number of specific disorders in
recommend a baseline electrocardiogram because of the risk which visual hallucinations are the primary feature.
of prolonged QTc interval resulting in torsades de pointes,
ventricular fibrillation and sudden death. In patients with
Lewy body dementia and delirium an alternative to haloperi-
dol would be lorazepam 0.5 to 1 mg (to a maximum of 3 mg
per 24 hours).
338
Organic disorders CHAPTER 13
Charles Bonnet syndrome usually follows an acute Wernicke’s encephalopathy, hence
Wernicke–Korsakoff syndrome. Wernicke’s encephalopathy is
This presents with a syndrome of complex visual hallucina- characterised by confusion, ataxia, nystagmus and ophthalmo-
tions in patients who have ocular disease causing visual loss. plegia. There can also be peripheral neuropathy. Wernicke’s
The images are usually clear, highly detailed, colourful and encephalopathy is a medical emergency, and parenteral admin-
moving. The majority of images are of people and are istration of high-dose vitamins to prevent the development of
frequently Lilliputian. The images tend to disappear on eye the chronic amnestic syndrome is indicated.
closure (unlike drug-induced states which worsen). Insight is
preserved although many patients fear insanity and will Patients with the chronic Korsakoff syndrome may perform
not disclose their symptoms. The hallucinations have been well on standard tasks of attention and working memory (serial
traditionally described as benign and comforting but a majority sevens and reverse digit span), but may struggle on more com-
of patients actually describe being disturbed by them. The plex tasks involving shifting and dividing attention. Memory
aetiology is uncertain. Direct damage to the visual system impairments involve both anterograde and retrograde deficits.
is common but increasing reports link the disorder to intrace- Defective encoding of new information has been implicated
rebral disruption to the visual pathway. A number of investiga- as a core to the memory disorder. Some learning may be
tors have postulated a link with Lewy body dementia but possible particularly if patients are given a strategy to follow.
this has not yet been convincingly established. Charles Bonnet Confabulation commonly occurs, particularly early in the
syndrome has also been reported secondary to Alzheimer’s dis- disorder. Procedural memory remains relatively intact.
ease, stroke and meningioma. Treatment involves sympathetic
explanation and improving vision where possible. The pathology consists of neuronal loss, microhaemorrhages
and gliosis in the periventricular and periaqueductal grey
Peduncular hallucinosis matter. The mamillary bodies, the mamillothalamic tract and
the anterior thalamus appear to be the key structures involved.
This is also known as L’hermitte syndrome and consists of There is also likely to be a degree of generalised cortical
complex, mobile visual hallucinations, often accompanied by atrophy, more marked in the frontal lobes. This may be non-
sleep disturbance and agitation, secondary to lesions in the specific, secondary to the years of alcohol abuse. MRI indicates
midbrain, pons, mesencephalon or paramedian thalamus. The specific atrophy in diencephalic structures (Fig. 13.7).
disorder was classically described as a rare complication of
stroke but has been more recently described following tumour The prognosis is variable. For the acute episode, one-
compression of brainstem and as a complication of inter- quarter of patients recover, half improve but have some persis-
ventional radiology. It usually resolves spontaneously. tent impairment and the remaining quarter remain severely
Amnestic syndromes
The amnestic or amnesic syndrome describes a condition in
which learning and memory are affected out of all proportion
to other cognitive functions, in an otherwise alert and respon-
sive patient. The most common cause is Wernicke–Korsakoff
syndrome as a result of nutritional depletion and in particular
thiamine deficiency. Other causes include carbon monoxide
poisoning, herpes simplex encephalitis and other infections
(see the section on dementia), hypoxic and other acquired
brain injuries (see the section on acquired brain injury), vascu-
lar disorders (stroke), deep midline cerebral tumours and
surgical resections. In the vast majority of cases the pathology
lies in midline or medial temporal structures, but there are a
number of case reports of amnestic disorder following frontal
lobe lesions.
Wernicke–Korsakoff syndrome
Wernicke–Korsakoff syndrome is the result of thiamine Fig. 13.7 MRI scans in Wernicke–Korsakoff syndrome frequently
depletion, and any cause of this can lead to the syndrome show atrophy in the diencephalon.
(Zubaran et al 1997). The overwhelming majority of cases
arise secondary to alcohol abuse as a result of decreased intake
and absorption of thiamine. A genetic defect for thiamine
metabolism has been described in a proportion of patients.
The chronic amnestic or Korsakoff syndrome (or psychosis)
339
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Companion to psychiatric studies Book 1
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