intro Flashcards
How are psychiatric conditions categorised?
Organic and functional
then psychotic and non psychotic
What are organic psychotic diseases?
delerium, epilepsy, other psychosis e.g. drugs
what are organic non-psychotic diseases?
Anxiety due to hyperthyroidism
What are functional psychotic diseases?
psychosis, depression, schizophrenia, mania
what are functional non-psychotic diseases?
OCD, phobias, depression
What is the order in which psychiatric diseases should be prioritised?
Organic disorders
Functional psychosis
Non-psychotic disorders
Personality disorders
what is needed to detain a patient?
Suffering from mental disorder (but may not be formally diagnosed)
AND
At risk to own health AND/OR own safety AND/OR risk to others AND/OR risk of serious neglect/exploitation
AND
Unwilling to go to hospital voluntarily
Which people are needed to section people?
• Assessed by 2 Drs (preferably one which already knows patient – GP) and 1 AMPH
o One doctor must be section 12 approved
• Each Dr must determine their own criteria for detention
• The AMPH is always responsible for making the application and can disagree with and overrule Drs
o Nearest relative can rarely act as AMPH
• Actual detainment is from hospital managers
What is a section 2?
Admission for assessment
• Grounds: MH disorder
• For: assessment (some treatment can be given but only for mental disorder or direct results/causes)
• Max duration: 28days
• Appeal: w/i 14 days
• Applied by: AMPH +2 Drs (1 approved)
• CANNOT BE RENEWED – MUST CONVERT TO SECTION 3
What is a section 3?
Admission for Rx
• Grounds: MH disorder
• For: Rx of the mental disorder/cause of mental disorder and consequences of mental disorder
• Max duration: 6months
• Appeal: Within the first 6 months then every time it’s renewed
• Can be renewed – two chunks of six months then after that renewed yearly)
• Applied by: AMPH + 2 Drs (must have seen pt w/i 24 hrs, 1 approved)
• Lots of travel/ insurance implications so reluctant to use this unless necessary.
What is a section 5(2)?
Drs Holding Power
Grounds: detention of inpatient only (not A&E), MH disorder
• Demonstrate a mental disorder
• Identify associated risks (to self/others)
• State why continued informal admission is not possible (refusal to stay/lack capacity to make decision)
• State that therefore person needs formal assessment under MHS
• For: allows time for MHA assessment - sec 2/3 to be acted (no authority to treat during these 72 hours!! (physically or mentally))
• Max duration: 72hrs
• Cannot be appealed, only released by responsible clinician
• Applied by: consultant in charge of care, or nominated deputy, FY2 or above
What is a section 5(4)?
nurses holding power
same as Dr but 6 hours
What is a section 4?
- Grounds: urgent detainment for assessment of person in public, may then convert sec 2. No authority to Rx
- Duration: 72hrs
- Applied by: AMPH + any registered Dr (FY2+)
What is a section 7?
Guardianship
Guardian has powers to
• Require pt to live at specified place
• Require pt to attend specified place for training/medical assessment
• Allow health worker to see patient in own home
o Cannot force pt to receive Rx
What is a section 17?
AUTHORISED LEAVE
• Responsible clinician allows detained patient to leave hospital for a certain period of time,
• Also includes CTO to receive treatment in community. But they can recall you anytime and give you immediate treatment if necessary - e.g. they can be brought back in to have a depot every month if not compliant.
• Also have to live under certain conditions. While on CTO you have right to an IMHA (independent mental health advocate)
What is a section 117?
- A patient under section 3 is automatically placed under Section 117 at the time of discharge from the Section 3. Under Section 117 it is the duty of the local health services to provide aftercare, with a care package aimed at rehabilitation and relapse prevention.
- The patient is under no obligation to accept this aftercare
What is a section 135?
o Police warrant for search and removal of pt -if MH disorder and being neglected/unable to care for themselves Removal from private area e.g. a patient’s home, to place of safety. Police get AMPH to apply to magistrate for this.
What is a section 136?
o Police officer may detain patient in public place if they suspect MH disorder to take to safe place e.g. 136 suite
o 24 hours
what is a section 37?
o Sent by courts to hospital (rather than prison)
what is a section 41?
o Restriction disorder. Conditional discharge. E.g. you are released from hospital as long as you live at a certain address and comply with treatment
what is a section 62?
o Allows treatment without consent. Need a SOAD (second opinion appointed doctor) to justify that the treatment is clinically indicated. Lasts for 28 days.
what are the rules for reviewing treatment under section?
- you can treat a patient without capacity without consent for up to 3 months
- . If a patient lacks capacity after 3 months and still disagrees to treatment, the clinician must fill out a T3 form (Consent to Treat). It is good practice to repeat this after a year.
- If the patient has capacity after 3 months and agrees to treatment you fill out a T2 form. This specifies exactly what treatment is being given – you must only give this otherwise it’s assault.
Who sits in on review tribunals?
- Legal member (usually a solicitor or a barrister),
- Doctor (usually a psychiatrist)
- Lay member (a person who is not medically or legally trained) with some mental health experience.
- You, the Responsible Clinician and social worker will also be at the tribunal obviously
- Patient can also choose to attend
How do you decide someone lacks capacity?
- A person is always assumed to have capacity
- MCA is decision-specific & time-specific
2 stage process 1 Diagnostic test a. At the time of the decision the pt has an impairment of or disturbance in functioning of the mind or brain 2 Functional test, inability to a. Understand info relevant to decision b. Retain that info c. Use or weigh that info d. Communicate their decision
What do you do if someone lacks capacity?
If no capacity, make decision in their BEST INTERESTS (consider waiting until they regain capacity, person’s past & present wishes, beliefs/values, views of anyone named by pt, POA)
What are the rules around capacity in minors? (5)
As far as possible minors ought to be involved in decisions about their care, whether or not they are deemed competent.
• Decisions on behalf of a minor can be made by a person with parental responsibility or by High Court
• 16 and 17 year olds are deemed competent by the same standards as adults (Family Law Reform Act 1969).
o However, they cannot refuse treatment if it has been agreed by a person of parental responsibility or the Court, and it is in their best interests
• UNDER 16S MAY BE DEEMED COMPETENT to accept an intervention if they are mature enough to fully understand what is proposed (Gillick competency/Fraser guidelines)
o Competency must be proved
• Ideally, the consent of a person with parental responsibility should also be sought. However, the decision of a competent minor to accept treatment cannot be overruled by a parent
• A court order may be obtained to overrule the decision of a competent minor or parent if it is considered in the best interests of the minor
What are some considerations around psych issues in pregnancy?
- Previous postpartum depression (PPD) gives a 50% risk in next pregnancy
- Previous postpartum depression + bipolar gives 75-100% risk in next pregnancy.
- 1/7 chance of post-partum relapse if had treatment in secondary care for a psychiatric condition.
- Use Edinburgh post-natal depression scale
- PND can deteriorate into PNP or PNP can be a stand alone condition
- Differentiate from ‘Baby blues’ which affect 80% new mothers in the first 2 weeks. Should settle by four weeks. If severe symptoms over 2-4 weeks, start thinking of PND.
- Can also get ‘Baby pinks’ – hypomania or mania.
Are SSRIs safe in pregnancy?
o First trimester probably not teratogenic. Can get postnatal adaptation syndrome (8-48hrs transient): Jittery, irritable, crying, poor feeding and poor temperature regulation.
o Breastfeeding generally fine at full term. Sertraline 1% in breast milk. Fluoxitine 4-6%. As long as less than 10% should be safe.
is venlafaxine safe in pregnancy?
o Increased risk of postnatal adaptation syndrome. HTN risk – pre-eclampsia, but should be ok and breastfeeding fine.
Are antipsychotics safe in pregnancy?
o If stable and likely to relapse without in pregnancy, advise to continue (NICE).
o Atypicals - breast feeding should be OK.
o Don’t breastfeed on clozapine – risk of agranulocytosis.
o Olanzepine and quetiapine best.
o Increased prolactin not great for fertility so may switch to atypical.
Are mood stabilisers safe in pregnancy?
o Patients with BAD have a 25% risk of developing PPP if not on mood stabiliser
o Valproate = MAJOR TERATOGEN!! – NOT FOR WCBP (women of child bearing potential)
o Lithium = increases risk of CV defects from 1% to 2-4%
So benefits of lithium may outweigh minor teratogenic effects
Up to patient
Define dysthymia
A chronic state of low mood, usually with an insidious onset and lasting at least two years
define euthymia
Happy, contented mood
define mood
A word used to describe sustained and pervasive emotions
define affect
Short-lived observable pattern of behavior that expresses the subjective emotional state of an individual. It is subject to variation over brief periods of time.
define alexithymia
An inability to verbally express one’s emotions
define anhedonia
Inability to enjoy anything in life or even get accustomed satisfaction from everyday events.
define psychomotor retardation
The subject sits abnormally still or walks abnormally slowly or takes a long time to initiate movement.
define flight of ideas
Rapid flow of thought, manifested by accelerated speech with abrupt changes between topics, although there is often some link. Loss of normal structure of thought appearing illogical or muddled. Sometimes seen in manic patients.
define pressure of speech
The subject talks too much. There seems to be undue pressure to get the words out. He speaks too fast, his voice is too loud and unnecessary words are added
define depersonalisation
A peculiar change in the awareness of self in which patient feels as if they are not real and detached. May feel they’ve changed and that the world around them is vague, dreamlike or lacking in significance. Retains some understanding and knows condition is abnormal.
define derealisation
The subject experiences his surrounding as unreal. An office or bus or a street seems like a stage set with actors, rather than real people going about their business. Everything seems colourless, artificial and dead. The subject retains a measure of understanding and knows that the condition is abnormal
define illusion
A false perception of a real stimulus.
define illusion of completion
Brain completes shapes
define affect illusion
Sensory stimulus is real but your affect affects the way your brain understands it. E.g. if you’re scared
define paridolic illusion
Sensory is real, but brain understands it in a different way. Finding patterns where they don’t exist e.g. in pancakes
define pseudo-hallucination
A perceptual experience, which is figurative, not concretely real and occurs in inner subjective space, not in external objective space. It has the quality of an idea.
Vivid enough sensory experience to be regarded as a hallucination but recognized by the subject not to be a result of external stimuli and therefore not real.
define hallucination
A perception, which occurs in the absence of a stimulus. It is false but to the person experiencing it, it has the full force and impact of a real perception and is consequently indistinguishable from real life.
- Occurs in the outer space
- Not shared by others
- Not under your control
- Omnipresent
- Impact on behaviour/ affect
define thought echo
The subject experiences his own thoughts as if they were being spoken aloud. May not be a simple echo but subtly or grossly changed in quality.
define thought insertion
The subject experiences thoughts, which are not his own intruding into his mind. In the most typical case the alien thoughts are said to have been inserted into the mind from outside, by means of radar telepathy or some other means.
define thought withdrawal
The subject says his thoughts have been removed from his head by an external agency so that he has no thoughts (often able to describe the sensation of the thoughts leaving)
define thought broadcast
The subject experiences his thoughts are being shared with people e.g. by telepathy, TV, radio
define delusions of control/passivity
Subject believes their thoughts/actions/feelings are not their own. They believe they are being controlled from outside. E.g. someone else’s words are coming out of their mouth.
define delusional perception
Sensory stimulus is real. Delusional thought attached. A type of primary delusion. This is present when the patient receives a normal perception which is then interpreted with delusional meaning and has immense personal meaning e.g. on seeing a traffic light change from red to green, a man declared he was the King of Mars.
define negative symptoms
Cluster of symptoms that often occur together in chronic schizophrenia: Poverty of speech, flat affect, poor motivation and poor attention. May result in low activity/ poor self-care.
define clouding of consciousness
This represents a step down from normal alertness. There is deterioration in thinking, attention, perception and memory and usually drowsiness and reduced awareness of environment.
define lability
The subject’s affect is rapidly changeable and there are marked fluctuations. May be cheerful and smiling then shortly after crying. In its extreme form we may use the word emotional incontinence.
define delusion
A fixed, firmly held belief that is held with unshakable conviction despite overwhelming evidence to the contrary and cannot be explained by the subject’s cultural or religious background.
define nihilistic delusions
Delusion of extreme negativity – no longer existing, about to die or even being dead. About to experience a terrible doom.
define grandiose delusions
Delusions of being of special status or significance, or having special powers or attributes, or a special mission or purpose.
define aphasia
No speech, inability to produce words orally
define concrete thinking
Inability to understand abstract ideas or concepts, literalness of understanding or expression
define second person auditory hallucinations
“You’re going to die, you’re going to die”
define third person auditory hallucinations
“The voices are talking to each other about me, they say I am evil and mad”
define ideas of reference
Delusional belief that innocuous events or coincidences are directly linked and have personal significance.
define loosening of associations
Loss of normal, structured thinking
define neologisms
New words with no real meaning
define perseveration
The repetition of a particular response (e.g. phrase, word, utterance, gesture) despite the absence or cessation of the stimulus. May occur in organic brain disorders.
define tangentiality
Going off on a tangent
define circumstantiality
Talks around the topic for ages and never gets to the point
define echolalia
The repetition of phrases, words or parts of words. Echolalia may be a sign of autism, another neurological condition, a visual impairment or a developmental disability.
