Introduction (Hx, Ex, Risk etc.) Flashcards
risk assessment structure
self: DSH, suicide, self-neglect, deterioration, exploitation
others: aggression/violence, dependence
other risk: driving, property, education/employment
MHA principles
3 parts: mental illness (not substances)? risk? appropriate care available?
3 professional: 2 doctors, one specially trained (SW, AMHP); consult NOK
MCA principles
2 stage test: illness affecting brain? affecting decisions (understand, retain, evaluate, communicate)?
assume capacity UPO; help as much as possible to get capacity; unwise is not incapable; best interests; least restrictive
differentials
psychiatric illnesses: think groups
dementia, delirium
physiological: thyroid, liver, anaemia, vitamin deficiency, renal failure, phaechromocytoma, calcium, porphyria
substance abuse:
common investigations
collateral history, GP notes
home visits
bloods: FBC, EUC, LFT, TFT, B12/folate, Ca, BM
UA, cultures
ECG, CXR, EEG
Neuroimaging
impact of disorders
BPS
diagnosis distress
stigma: dismissed, employment, public abuse, prejudiced health services, finance/insurance
factors influencing engagement, and Mx
insight and direct illness effects (delusions, avolition, cognition)
SE, low benefit, enjoy being unwell, dependence worries, stigma
substance abuse, chaotic lifestyle, complex regimes
identify reason and re-educate; capacity and insight
reduce SE, optimise dose, try alternatives, comorbidities
access: e.g. depot, supervised consumption, community support
motivational interviewing (motivation and ambivalence)
classification (ICD-10)
F0: organic
F1: psychoactive substances
F2: schizophrenia and delusional disorders (psychosis)
F3: mood disorders
F4: neurotic, stress-related, and somatoform disorders
F5: behavioural syndrome/MH with physiological/hormone dysfunction
F6: adult personality/behaviour disorders
F7: mental retardation
F8: psychological development
F9: CAMHS
psychological models
psychodynamic: feelings, identity, emotions; past influences
cognitive behaviour: thoughts, feelings, behaviours, attitudes; current erroneous thinking and maladaptaion
social: life events, maladjustment, stressors
General stats
25% life time risk of MH issues; 10% of kids
mortality: schiz 4.8, severe mood 4.9, mild mood 2.4, substances 18.0, personality 3;
male MH mortality 6.1, female 2.8; average 20y premature
direct cost £77b per year, 14% of NHS spend; not including indirect costs
Levels of care:
based on: risk, function, co-morbidity, environment/stressors, history, engagement
I: community; recovery maintenance; infrequent
II: primary care; ongoing low intensity community services; regular
III: primary care; high intesnity community services; frequent
IV: secondary care; MDT; intensive programmes
V: secondary care; residential treatment
VI: tertiary care; inpatient services
based on risk
specialist teams
crisis team: 24/7; ST Mx at home; prevent Ax; crisis houses
early intervention e.g. EIP: reduced DUP, intensive f/u
assertive outreach: intensive contact for engagement/risk
liaison: gen Hospital teams
mother and baby units: perinatal; avoid separation
eating disorders: community and inpatient (regional)
personality disorders: community and inpatient; high-security hospitals
common MH in primary care
87% present with insomnia, tension headaches, physical disease (1/3 are psych)
somatisation: very common; abdo, chest, back, headache; stress
substance abuse: supsicious drugs (DF118), new reg/unreg’d, alcohol abuse comorbidities
depression: very common, often missed (50% Dx 1st consult, 40% missed, 20% unDx for 6/12)
psychosis (4%): 25% OPd, 72% IP
neuroses (64%): 44% OPD, 18% IP
referral to secondary care indications
treatment resistance unclear diagnosis specialist investigations: CT, EEG etc intensive treatment (high risk): ECT, psychotherapy, megadose, some APDs, CMHT patient request
BPS management:
history, MSE, exam, investigations, risk and capacity, level of care, follow-up
biological: medications, ECT, comorbidities, substance abuse
psychological: psychoeducation, self-help, counselling, CBT, PDT, group therapy, FIT etc
social: lifestyle changes, stressors; education/employment, finance, housing, relationships, carers, social inclusion/hobbies
History pointers
reason for referral: who? insight? expectations
HPC: time course/fluctuations; symptoms incl. impact; treatments/effect
PPH: incl. DSH, SI, Ax, MHA; pre-morbid history (self/others opinion too)
personal history: childhood (birth, school, abuse), adult (relations, support, work)
forensic history; current SH (incl. support)
signpost, explain reasoning, normalise Sx, screening Qs
‘DOCTAR’
duration onset: acute/chronic chronology: episodic, continuous, fluctuating triggers and treatments aggravating factors relieving factors
common presentations
confusion: dementia, delirium, other organic, pseudodementia
bizarre behaviour: mania, dementia, organic, OCD, ADHD
dangerous behaviour: functional or dysfunctional; risk taking
physical symptoms
interpersonal relationship difficulties
emotional distress, affects function
MSE
appearance/behaviour: clothing, habitus, eye contact, expression, movement, social behaviour
mood: obj/subj; lability, congruence; mood and affect
speech: rate, volume, quality, fluency; flight/thought disorder
thought: form (flight, accel/decel, dissoc), content (delusion, overvalued, obsession, alientation)
cognition: alert, orientated, memory, concentration/attention, frontal lobe (MOCA)
perception: hallucination, illusion, pseudohallucination, depersonalisation, derealisation
insight: Awareness (ill?), Attribution (psych?), Acceptance (treatment?)
immediate management
investigations: collateral history, notes/GP info, blood tests, ECG, neuroimaging
treatments: BPS; make safe
explanations
I EAT PIE: epidemio, aetio, treatment, prognosis
I MAST DIE: indication, mechanism, adv., SE, treatment course, discontinue/alternatives
specialisms
general adults: 18-65
children/adolescents 65yo
factors affecting GP diagnosis
26-32% with diagnosable illness
only 23% feel ‘ill’ and attend; only 10% detected; 2.4% referred, 0.06% admitted
less likely to present: somatic, concurrent physical illness, mild/atypical Sx, male, young, unmarried, educated, taciturn, less insight
more likely: female, unemployed, life stressors
doctor: non-verbals, patient expectations/experience, longer consultations, empathy, listening skills, ID high risk groups
Risk assessment - RF
self: history, PD, substances, unemployed, social class, violence, single
suicide (static): DSH, serious previous, PPH, substances, PD, childhood, FHx, male, old, single
suicide (dynamic): SI/intent, hopeless, psych Sx, substances, Ax and recent d/c, stress, poor problem-solving
suicide (future): access, poor f/u, poor Rx, future stressors
to others: violence, young male, social network, unemployed, psychotic, substances, Rx, MSE, situation/access, command, insight
deterioration: concordance
driving: severe anx/depp, mania/ psychosis (DVLA)
Obs levels
I: highest; 1:1 arms length
II: high risk; 1:1 eyesight
III: 15m location; leave with responsible adult
IV: hourly location; can leave alone
Rapid tranquillisation:
only if psychological Mx failed
PO first: lorazepam, APDs (onlanz, risp, halo)
encourage PO if refused
IM if PO failed: loraz, promethiazine, olanz (not if BZD), halo
