Three themes can be discerned in contemporary psychiatry: the growing unity of the subject, the pace of scientific advance, and the growth of practice in the community. We have sought to reflect these themes in the New Oxford Textbook of Psychiatry and to present the state of psychiatry at the start of the new millennium. The book is written for psychiatrists engaged in continuous education and recertification; the previous, shorter, Oxford Textbook of Psychiatry remains available for psychiatrists in training. The book is intended to be suitable also as a work of reference for psychiatrists of all levels of experience, and for other professionals whose work involves them in the problems of psychiatry.
The growing unity of psychiatry
The growing unity in psychiatry is evident in several ways. Biological and psychosocial approaches have been largely reconciled with a general recognition that genetic and environmental factors interact, and that psychological processes are based in and can influence neurobiological mechanisms. At the same time, the common ground between the different psychodynamic theories has been recognized, and is widely accepted as more valuable than the differences between them.
The practice of psychiatry is increasingly similar in different countries, with the remaining variations related more to differences between national systems of health care and the resources available to clinicians, than to differences in the aims of the psychiatrists working in these countries. This unity of approach is reflected in this book whose authors practise in many different countries and yet present a common approach. In this respect this textbook differs importantly from others which present the views of authors drawn predominantly from a single country or region.
Greater agreement about diagnosis and nosology has led to a better understanding of how different treatment approaches are effective in different disorders. The relative specificity of psychopharmacological treatments is being matched increasingly by the specificity of some of the recently developed psychological treatments, so that psychological treatment should no longer be applied without reference to diagnosis, as was sometimes done in the past.
The pace of scientific advance
Advances in genetics and in the neurosciences have already increased knowledge of the basic mechanisms of the brain and are beginning to uncover the neurobiological mechanisms involved in psychiatric disorder. Striking progress has been achieved in the understanding of Alzheimer's disease, for example, and there are indications that similar progress will follow in uncovering the causes of mood disorder, schizophrenia, and autism. Knowledge of genetics and the neurosciences is so extensive and the pace of change is so rapid that it is difficult to present a complete account within the limited space available in a textbook of clinical psychiatry. We have selected aspects of these sciences that seem, to us and the authors, to have contributed significantly to psychiatry or to be likely to do so before long.
Psychological and social sciences and epidemiology are essential methods of investigation in psychiatry. Although the pace of advance in these sciences may not be as great as in the neurosciences, the findings generally have a more direct relation to clinical phenomena. Moreover, the mechanisms by which psychological and social factors interact with genetic, biochemical, and structural ones will continue to be important however great the progress in these other sciences. Among the advances in the psychological and social sciences that are relevant to clinical phenomena, we have included accounts of memory, psychological development, research on life events, and the effects of culture. Epidemiological studies continue to be crucial for defining psychiatric disorders, following their course, and identifying their causes.
Psychiatry in the community
In most countries, psychiatry is now practised in the community rather than in institutions, and where this change has yet be completed, it is generally recognized that it should take place. The change has done much more than transfer the locus of care; it has converted patients from passive recipients of care to active participants with individual needs and preferences. Psychiatrists are now involved in the planning, provision, and evaluation of services for whole communities, which may include members of ethnic minorities, homeless people, and refugees. Responsibility for a community has underlined the importance of the prevention as well as the treatment of mental disorder and of the role of agencies other than health services in both. Care in the community has also drawn attention to the many people with psychiatric disorder who are treated in primary care, and has led to new ways of working between psychiatrists and physicians. At the same time, psychiatrists have worked more in general hospitals, helping patients with both medical and psychiatric problems. Others have provided care for offenders.
The organization of the book
In most ways, the organization of this book is along conventional lines. However, some matters require explanation.
Part 1 contains a variety of diverse topics brought together under the general heading of the subject matter and approach to psychiatry. Phenomenology, assessment, classification, and ethical problems are included, together with the role of the psychiatrist as educator and as manager. Public health aspects of psychiatry are considered together with public attitudes to psychiatry and to psychiatric patients. Part 1 ends with a chapter on the links between science and practice. It begins with a topic that is central to good practice—the understanding of the experience of becoming a psychiatric patient.
Part 2 is concerned with the scientific foundations of psychiatry grouped under the headings neurosciences, genetics, psychological sciences, social sciences, and epidemiology. The chapters contain general information about these sciences; findings specific to a particular disorder are described in the chapter on that disorder. Brain imaging techniques are discussed here because they link basic sciences with clinical research. As explained above, the chapters are selective and, in some, readers who wish to study the subjects in greater detail will find suggestions for further reading.
Part 3 is concerned with dynamic approaches to psychiatry. The principal schools of thought are presented as alternative ways of understanding the influence of life experience on personality and on responses to stressful events and to illness. Some reference is made to dynamic psychotherapy in these accounts, but the main account of these treatments is in Part 6. This arrangement separates the chapters on the practice of dynamic psychotherapy from those on psychodynamic theory, but we consider that this disadvantage is outweighed by the benefit of considering together the commonly used forms of psychotherapy.
Part 4 is long, with chapters on the clinical syndromes of adult psychiatry, with the exception of somatoform disorders which appear in Part 5, Psychiatry and Medicine. This latter contains more than a traditional account of psychosomatic medicine. It also includes a review of psychiatric disorders that may cause medical symptoms unexplained by physical pathology, the medical, surgical, gynaecological, and obstetric conditions most often associated with psychiatric disorder, health psychology, and the treatment of psychiatric disorder in medically ill patients.
Information about treatment appears in more than one part of the book. Part 6 contains descriptions of the physical and psychological treatments in common use in psychiatry. Dynamic psychotherapy and psychoanalysis are described alongside counselling and cognitive behavioural techniques. This part of the book contains general descriptions of the treatments; their use for a particular disorder is considered in the chapter on that disorder. In the latter, the account is generally in two parts: a review of evidence about the efficacy of the treatment, followed by advice on man-agement in which available evidence is supplemented, where necessary, with clinical experience. Treatment methods designed specially for children and adolescents, for people with mental retardation (learning disability), and for patients within the forensic services are considered in Parts 9, 10, and 11 respectively.
Social psychiatry and service provision are described in Part 7. Public policy issues, as well as the planning, delivery, and evaluation of services, are discussed here. Psychiatry in primary care is an important topic in this part of the book. There are chapters on the special problems of members of ethnic minorities, homeless people, and refugees, and the effects of culture on the provision and uptake of services.
Child and adolescent psychiatry, old age psychiatry, and mental retardation are described in Parts 8, 9, and 10. These accounts are less detailed than might be found in textbooks intended for specialists working exclusively in the relevant subspecialty. Rather, they are written for readers experienced in another branch of psychiatry who wish to improve their knowledge of the special subject. We are aware of the controversy surrounding our choice of the title of Part 10. We have selected the term ‘mental retardation’ because it is used in both ICD-10 and DSM-IV. In some countries this term has been replaced by another that is thought to be less stigmatizing and more acceptable to patients and families. For example, in the United Kingdom the preferred term is ‘learning disability’. While we sympathize with the aims of those who adopt this and other alternative terms, the book is intended for an international readership and it seems best to use the term chosen by the World Health Organization as most generally understood. Thus the term mental retardation is used unless there is a special reason to use another.
In Part 11, Forensic Psychiatry, it has been especially difficult to present a general account of the subject that is not tied to practice in a single country. This is because systems of law differ between countries and the practice of forensic psychiatry has to conform with the local legal system. Although many of the examples in this part of the book may at first seem restricted in their relevance because they are described in the context of English law, we hope that readers will be able to transfer the principles described in these chapters to the legal tradition in which they work.
Finally, readers should note that the history of psychiatry is presented in more than one part of the book. The history of psychiatry as a medical specialty is described in Part 1. The history of ideas about the various psychiatric disorders appears, where relevant, in the chapters on these disorders, where they can be considered in relation to present-day concepts. The history of ideas about aetiology is considered in Part 2, which covers the scientific basis of psychiatric aetiology, while the historical development of dynamic psychiatry is described in Part 3.