Collaborative psychiatric management is founded on a person-centred, holistic assessment leading to a diagnostic formulation that guides decision making. Formulation around the individual person, including their unique history and worldview, can be described with presenting, precipitating, predisposing, perpetuating and protective factors as well as the life context for the individual patient. Allied with this, diagnosis – in which the patient’s unique presentation can be evaluated as sharing characteristics and patterns with other patients – can allow for the individual plan to be guided by a wider frame of reference and knowledge. Such diagnostic frameworks have been developed over millennia and across cultures. As well as being important for individual patient care, they are essential for research and service planning. The development of these diagnostic frameworks is discussed with particular reference to the main international classifications of ICD-11 and DSM-5. It is common for people to have more than one diagnosis, and diagnostic hierarchies are considered. Criticisms of the construct of psychiatric diagnosis are reviewed, and an approach to conducting and describing collaborative psychiatric assessment is described.

This chapter considers how to care for patients who meet the criteria for a diagnosis of personality disorder. We reflect on the role of the psychiatrist in creating a resilient, honest and caring clinical environment, delivering interventions in a considered and coherent manner. Central to this is the relationship between doctor and patient, which includes not only direct clinical care but also the orchestration of work across the multi-disciplinary team and other agencies through clinical leadership.

We approach personality disorders as a relational problem in which the patient experiences their difficulties through their relationships with themselves and the world around them. These difficulties often, though not exclusively, are a developmental consequence of adverse childhood experiences, brought to life within the therapeutic relationship itself. This inevitably means the work is challenging, but it also means that the way we comport ourselves and lead becomes central to the therapeutic culture.

Much has been written on the challenges of working with people who are diagnosable with personality disorder, but perhaps less acknowledged is how these challenges represent not only the very material fundamental to our primary task but also the reason it is such rewarding work given the right circumstances.

Personality disorder represents a diagnosis very different from others in psychiatry. This is because it describes a long-standing integral part of a person, not just an affliction that has happened. Because of the sensitivity of ascribing a core part of a person’s being to the impersonality of a diagnostic term, the subject has been widely stigmatised. However, the condition is very common and affects one-tenth of the population. In this chapter, the clinical features of personality disorder identified in the new ICD-11 severity classification are described and their value illustrated. A fuller description of the ICD-11 classification can be found in another College publication.

There are five levels of diagnosis of personality disorder, including the sub-syndromal form – personality difficulty – which is by far the most common. The diagnosis of borderline personality disorder is the most used in practice but is a heterogeneous term that overlaps with almost every other disorder in psychiatry. All personality disorders have approximately equal genetic and environmental precursors, and the involvement of childhood adverse experiences and trauma is unfortunately true for this as for all psychiatric disorders.

This chapter emphasises the importance of the physical health history to holistic psychiatric case assessment. It describes the general approach to this and sets this particularly in the context of patients with serious or severe mental illness. Such patients have substantially increased morbidity and mortality from physical causes compared to the general population, and this increased mortality has been clearly documented for nearly two hundred years. A practical, collaborative and optimistic multilevel approach to attempting to make a difference to these outcomes is described, concluding with fourteen broad, practical areas for achievable interventions.

Depression is a leading cause of disability in high- and middle-income countries and is of increasing relative burden in low-income countries. The Global Burden of Disease study illustrates how depression is increasing as a proportion of all the disabilities resulting from illness. This is because we know how to prevent other major causes of disability such as cardiovascular disease and infection and so their incidence is on the decline. Meanwhile, there is evidence that rates of depression are rising slightly. In order to have an impact on this major public health burden, we will need to devise preventative strategies to reduce the incidence. As depression is a continuum, much of the disability is experienced by the larger numbers of those with mild and moderate levels of depression who might not seek treatment for themselves. Therefore, effective preventative strategies applied to the whole population will have more widespread benefits than interventions simply targeted towards those at high risk. In order to develop preventative interventions, we need to know what causes depression.

Epidemiology tends to be primarily concerned with causes outside the individual or with genetic causes.

Depressive disorders have been recognised since antiquity, although how they have been described and understood has changed considerably over time. In this chapter, we outline key aspects of the history of depression as well as some of the limitations in its current classification in ICD-11 and DSM-5. We describe the range of symptoms experienced in depressive disorders, together with the recognised variations in clinical presentation and how these are conceptualised and classified. The relationship between depression and related disorders including anxiety disorders, premenstrual dysphoric disorder and grief is discussed, as well as boundary issues with bipolar disorder and primary psychotic disorders. We review current knowledge about depression’s considerable psychiatric and medical comorbidity, along with its epidemiology, natural history and health burden. A brief practical guide to assessing depressive disorders is given, together with rating scales that are useful for clinical assessment and monitoring.

Bipolar disorder is an affective disorder defined on the basis of the presence of periods of elevated mood. Patients often present with depression, and previous episodes of elevated mood may be missed if not specifically explored during assessment. Bipolar disorder may be difficult to differentiate from other conditions causing mood instability and impulsivity. It is important to identify comorbidities such as substance use, neurodiversity and physical illnesses. The first-line treatment for mania is antipsychotic medication. Antidepressants are reported to have little to no efficacy in treating bipolar depression on average. Lithium is not the only long-term prophylactic agent, but it remains the gold standard, with good evidence that it reduces mood episodes and adverse outcomes. Monitoring is required to ensure lithium level is optimised and potential side-effects minimised.

This chapter covers psychosocial and physical health approaches to the management of bipolar disorder. These include psychosocial and physical health approaches to the condition that should be offered by every psychiatrist, as well as specialist psychological treatments delivered by psychological therapists. The approach outlined is supported by the National Institute for Care Excellence (NICE) in its 2014 clinical guideline for bipolar disorder as well as other clinical guidelines for bipolar disorder more recently published from Canada, Australia and New Zealand. Overall, the current best standard of practice for bipolar disorder is to adopt a collaborative proactive holistic approach attending to both mental health and physical health stability without the use of unnecessarily high doses of medication, particularly when they may impact on physical health. The approach should be consistent with the life goals and wishes of the person with bipolar disorder, convey a message of hope, and consider lifestyle and cognitive factors alongside symptoms and function. Bipolar disorder is a long-term condition where there is a potential for normal function and a high quality of life for many. A psychologically informed approach to management enables people with bipolar disorder to be proactive in their care, practice self-management and do their best.

Psychiatry, according to Johann Christian Reil (1759–1813), the German anatomist who first coined the term, consists of the meeting of two minds, the mind of the patient with the mind of the doctor. As the patient’s story unfolds, the doctor’s task is to recognise the pattern and to do so with compassion. Pattern recognition lies at the heart of the diagnostic process throughout medicine and none more so than in psychiatry, which lacks almost all the special investigations that help clarify diagnosis in other medical specialities. Thus, detailed knowledge of the key features of all the psychiatric disorders, both common and rare, is the core body of information that the psychiatrist will need to acquire during their training years. Because of this, we have provided detailed descriptions of each and every disorder as well as their diagnostic criteria according to DSM-5 and ICD-11.

Psychosocial intervention, in its broadest sense, is a vital component in the management of all types of depression, from mild depressive reactions to psychotic episodes. Even if pharmacological therapy or ECT is the main treatment, the way in which the clinician assesses, engages the patient, gives information about the illness and its treatment, and provides support contributes significantly to a successful outcome. In addition to this basic level of supportive work, many patients will benefit from more structured forms of psychotherapy. This chapter will consider the psychological and social therapies available for depression and the evidence for their effectiveness. Some general principles of psychological management for the depressed patient will be described.

CL psychiatry is one of the newer sub-specialties of adult psychiatry and is concerned with the practice of psychiatry in non-psychiatric settings. Typically, this means in general hospital wards and outpatient clinics, although in some countries, it also includes liaison with primary care. In recent years, there have been important changes in general medicine relevant to CL psychiatry. There is now a much wider recognition of the high prevalence of psychiatric and physical comorbidity and how this influences consultation frequency, service utilisation, treatment adherence, the physical prognosis and probably the overall cost as well. The relationship between physical disease and mental disorder is influenced by biological factors contributing to psychological change in physical disease, psychological factors in physical disease, social factors and comorbidity. There has also been recognition of the high prevalence of non-organic complaints among general medical patients as well as an awareness of the high costs of investigating these patients, which has led to a search for better ways to manage this group of patients.

Collaboration between general medical and psychiatric staff is essential. Psychological treatment and psychotropic medication can be effective. Mental capacity is an important and sometimes complex issue.

Cultures are an integral part of a person’s life, and they influence an individual’s social and cognitive development. They can contribute to the onset, perpetuation and outcomes of many psychiatric illnesses. These have a major role in defining abnormal behaviours and deviance, but cultures can also heavily influence pathways to care by influencing explanatory models and resources. In addition, culture moulds an individual’s worldview. Cultures are incipient, with institutions of education, employment and training having their own microcultures. Individuals learn to navigate these multiple cultural and micro-identities in order to achieve their aims. The relationship between the culture and prevalence of various psychiatric disorders is complex. In recent times, for political and economic reasons, attitudes towards economic migrants as well as refugees and asylum seekers appear to have become more negative in high-income countries. Hence, it is important to recognise that cultures have relativist characteristics rather than universalist, though some features may be common in designing, developing and delivering services. The role of culture in mental illness is described in this chapter.

Patients with bodily distress, hypochondriasis and chronic pain experience symptoms that impair their functioning and cause them significant degrees of discomfort. They also represent a significant public health challenge. Problems in classification/nosology continue to bedevil this area, and these difficulties – along with the use of the language of psychiatric classification, which most patients find unacceptable – continue to led to the DSM/ICD terms being little used in day-to-day clinical practice, including liaison psychiatry. Biological, psychological and social factors are relevant to both the aetiology and the maintenance of these syndromes, as well as to their treatment. In recent years, a variety of effective biological and psychosocial approaches to treatment have been developed, and these patients can now be considered as a group for whom medical and psychological approaches should be offered.

This chapter gives an overview and update on functional neurological disorder (FND), also known as dissociative neurological symptom disorder and previously known as conversion disorder. FND is the presence of neurological symptoms that are not explained or explainable by a neurological disorder. FND has been assumed to be a purely stress-related psychiatric disorder, but over the recent decades, this simplistic conception has been supplanted by more nuanced models of symptom generation. FND is no longer a diagnosis of exclusion. Instead, wherever possible, it is ruled-in by distinct features of history and examination, the latter known as positive clinical signs. There have been concurrent advances in the biological understanding of FND, exemplified by functional neuroimaging studies that have indicated that FND can be distinguished from, for example, feigned symptoms mimicking the disorder. FND encompasses multiple subtypes, from seizures to motor disorders to sensory abnormalities. Symptoms often co-occur, sometimes in a striking fashion.

Current treatment options for FND are limited, and many patients have severe long-term symptoms despite best-available treatment including psychological therapies and medication. Nevertheless, there are simple, and sometimes effective, steps that clinicians can take to manage and treat patients.

In this chapter, we review how pregnancy and the postnatal period influence the manifestations of psychiatric disorder. Although rare, the postpartum psychoses can be devastating illnesses, occasionally associated with suicide and require timely treatments to bring them under control. Postnatal depression by contrast is a common and readily diagnosed disorder and responds well to standard treatments such as CBT and medication. However, it may have complex effects on mothering and the new-born in the early months following childbirth, and the present-day perinatal services that manage the bulk of these cases are reviewed here. Any psychiatric disorder can appear during pregnancy, and some conditions may worsen, but a few may paradoxically improve. The prescribing of medication to this population is a complicated task because of teratogenic risks – some known, others imagined – as well their safety in breast feeding, which is also reviewed. Effects on infants and children are important, so the chapter ends with a review of child abuse and neglect and its current diagnosis and management.

Differences in reciprocal social interaction and communication, intense focal interests, repetitive movements and sensory sensitivities. There are no traits or sensitivities that are unique to autistic people, but the combination of features and the degree to which they occur is what characterises the condition. There is ongoing debate about whether autism is a disorder, a condition or a naturally occurring difference. The lifetime experiences of autistic adults through into older life are still largely unknown. It is important to treat co-occurring conditions in autistic people with the evidence-based treatments used for non-autistic people until and unless clear evidence emerges showing a different approach is preferable. Autism is not a mental illness or learning disability. Rather, it is a difference where traits and sensitivities can have positive and negative impacts on a person’s life, and these impacts can change at different times or in different circumstances. It is vital to recognize and understand autism in order to make reasonable adjustments to the assessment and treatment plans when treating co-occurring disorder in an autistic person.

Mental health services are intended to provide the means to deliver interventions and care to people experiencing mental health problems. This can only be achieved if the staff and resources to provide interventions and care are available. Unfortunately, the current design and resourcing of services can seriously interfere with this happening. Services have evolved over centuries, and many practices are determined by convention and limited by resources, particularly availability of staff in sufficient numbers and with appropriate skills. Mental Health Service provision, commissioning and funding in the NHS, and the evidence base are rapidly developing. Community mental health services, early intervention, assertive outreach, inpatient, outpatient, intensive care units and home treatment teams form key components, but clinical and patient-rated outcomes are still too infrequently measured to guide service development. The complexity of these services and their interfaces with primary care and specialist mental health teams are discussed in this chapter.