Mental health - complete from notes/lectures Flashcards
Common conditions
What are the learning objectives of MH term?
- do a comprehensive pyschiatric asssessment including a case formulation
- understand basic psychopharmocology (e.g Lithium- indications, effects, side effects)
- understand basic pyshcological interventions
- Develop rapport
- Recognise pyschiatric disorders in these settings
- Risk assessment and risk management
What are important screening questions needed to cover for every patient in MH - when taking history (MSE etc)
Outline a complete psychiatric history?
what is an acronym to remember this?
1) ENGAGING THE PATIENT
A person sharing their life story, frequently involving trauma, to a person they have never met, who requires a lot of detail in a restricted amount of time, is a privilege.
• Be mindful of:
o Consent
o Confidentiality
▪ Not discussing details outside of health staff involved in the persons care
• Environment
o Privacy – bedside curtains are not sound proof
o Safe
o Comfortable
• Language – there is a lot of inherent judgement in choice of language (mad, crazy, dangerous). Be respectful.
INTRODUCTION
• Introduce yourself, your role, and the purpose of the assessment
• Discuss confidentiality
• To explore the presentation further, begin with an open question to invite the patient to tell you, in their own words, what has happened for them to be here today
• Use this time to observe the patient – this will make up a large part of the MSE
DEMOGRAPHICS
• Name, age, sex, ethnicity
• Mental health act status and method of arrival to facility
• Established dx
• Current rx
• Admission length
• Living situation/arrangements
• Relationship status/children——-> o Must be aware of dependent children
• Education level, Employment status/income or benefit if unemployed
PRESENTING COMPLAINT:
- → Brief summary of how and why the patient has presented for review at this point in time
- It is useful to have a brief look at the chart or referral to gather this information prior to seeing the patient
- Eg: Mr R was brought into hospital by QAS on and Emergency Examination Order following a concerned phone call from Mr R’s ex-wife that Mr R was suicidal
- Chief complaint in own words
- Reason for seeking help
- Current symptoms: does the patient appear manic, depressed, physical health, psychotic, anxious, substance user
- Timeframe
- Premorbid baseline
- Precipitants: 7D’s - death, drugs, didn’t take meds, debt, divorce, disease and developmental
HISTORY OF PRESENTING COMPLAINT
• This is the patient’s story of what they are experiencing and what has led to this presentation.
o Need to get a lot more of the details of what has happened
• This is also where we need to ask very specific questions about symptoms of mental illness.
WHAT DO WE NEED TO ESTABLISH HERE?
• Establish presence and absence of symptoms
• Establish a time frame
• Establish the severity of the symptoms
o ‘How does it affect your life?’
• Establish precipitating factors
• Establish perpetuating factors Eg: financial hardship, chronic pain
o What made it worse/better
• Establish the effect on the person Eg: suicidal thoughts, poor self-care, difficulty studying or attending work
• Establish supports/protective factors
PSYCHIATRIC HISTORY
• Diagnosis: timing, length, reasons
• Hospitalisation
• Prior admissions/contact with mental health
• Prior symptoms when unwell
• Treatment
• Medication history and compliance, side effects and source
• Prior psychological treatments (other than medication)
• Past suicide attempts/deliberate self-harm
• Need to consider
o What has this individual experienced in the past?
o Is there a pattern?
o What has been tried in the past?
o What has, and has not, worked?
DEVELOPMENTAL HISTORY:
• → A developmental history gives us clues as to risk factors for developing mental illness, any evidence of a prodromal state, and personality factors.
• Birth-
o History of maternal health (including illnesses such as influenza)/substance use during pregnancy
o Birth complications (?hypoxic damage)
• Childhood-
o Milestones-
o Childhood illnesses
o Relationship with siblings
o History of trauma
• Education-
o Academic performance ?to what year ?any deterioration
o Bullying
o Hx of suspension/expulsion ?why
o Post school aspirations
• Employment history-
o If many jobs, why have they changed? Fired?
o Training/qualifications
• Relationship history
o Quality of relationships? Able to form longer attachments?
o Friendship groups ?still in contact
MEDICAL HISTORY:
• Allergies
• Prescription medications
• Any associated legal, financial, social, health problems
• Personal history of:
o Thyroid disease
o Head injuries
o Seizure disorders
o Chronic pain/chronic illness
o Cardiac history
▪ Some conditions have cardiac and mental health associations
FAMILY HISTORY:
• Genogram sometimes helps
• Mental illness, suicide attempts, cardiac disease, diabetes, seizures, substance use, thyroid, psychiatric illnesses
SUBSTANCE USE HISTORY:
• Alcohol
o First use
o Current use (type, amount, frequency)
o Prior attempts to cease
o Hx of tolerance
o Hx of withdrawal symptoms, including of seizures
o Progression of use over time
o Previous history of treatment or abstinence
Marijuana/THC
• Other illicits
• ?IVDU
• Recreational drugs: what, when, how long, amount per week
FORENSIC HISTORY
• Current charges
o Violence
o Drugs
• Prior incarceration – history of lengths of sentences and when last released
• Juvenile history
COLLATERAL HISTORY
• OBTAIN CONSENT
• Often a very significant part of an evaluation for patients who are unable to give a coherent self-account or those who may be concealing information that would change your opinion or management
• Often needed prior to formulating risk/devising a mx approach
• When gathering collateral it is useful to see the patient and collateral provider together and alone
Outline a complete psychiatric history?
what is an acronym to remember this?
1) ENGAGING THE PATIENT
A person sharing their life story, frequently involving trauma, to a person they have never met, who requires a lot of detail in a restricted amount of time, is a privilege.
• Be mindful of:
o Consent
o Confidentiality
▪ Not discussing details outside of health staff involved in the persons care
• Environment
o Privacy – bedside curtains are not sound proof
o Safe
o Comfortable
• Language – there is a lot of inherent judgement in choice of language (mad, crazy, dangerous). Be respectful.
INTRODUCTION
• Introduce yourself, your role, and the purpose of the assessment
• Discuss confidentiality
• To explore the presentation further, begin with an open question to invite the patient to tell you, in their own words, what has happened for them to be here today
• Use this time to observe the patient – this will make up a large part of the MSE
DEMOGRAPHICS
• Name, age, sex, ethnicity
• Mental health act status and method of arrival to facility
• Established dx
• Current rx
• Admission length
• Living situation/arrangements
• Relationship status/children——-> o Must be aware of dependent children
• Education level, Employment status/income or benefit if unemployed
PRESENTING COMPLAINT:
- → Brief summary of how and why the patient has presented for review at this point in time
- It is useful to have a brief look at the chart or referral to gather this information prior to seeing the patient
- Eg: Mr R was brought into hospital by QAS on and Emergency Examination Order following a concerned phone call from Mr R’s ex-wife that Mr R was suicidal
- Chief complaint in own words
- Reason for seeking help
- Current symptoms: does the patient appear manic, depressed, physical health, psychotic, anxious, substance user
- Timeframe
- Premorbid baseline
- Precipitants: 7D’s - death, drugs, didn’t take meds, debt, divorce, disease and developmental
HISTORY OF PRESENTING COMPLAINT
• This is the patient’s story of what they are experiencing and what has led to this presentation.
o Need to get a lot more of the details of what has happened
• This is also where we need to ask very specific questions about symptoms of mental illness.
WHAT DO WE NEED TO ESTABLISH HERE?
• Establish presence and absence of symptoms
• Establish a time frame
• Establish the severity of the symptoms
o ‘How does it affect your life?’
• Establish precipitating factors
• Establish perpetuating factors Eg: financial hardship, chronic pain
o What made it worse/better
• Establish the effect on the person Eg: suicidal thoughts, poor self-care, difficulty studying or attending work
• Establish supports/protective factors
PSYCHIATRIC HISTORY
• Diagnosis: timing, length, reasons
• Hospitalisation
• Prior admissions/contact with mental health
• Prior symptoms when unwell
• Treatment
• Medication history and compliance, side effects and source
• Prior psychological treatments (other than medication)
• Past suicide attempts/deliberate self-harm
• Need to consider
o What has this individual experienced in the past?
o Is there a pattern?
o What has been tried in the past?
o What has, and has not, worked?
DEVELOPMENTAL HISTORY:
• → A developmental history gives us clues as to risk factors for developing mental illness, any evidence of a prodromal state, and personality factors.
• Birth-
o History of maternal health (including illnesses such as influenza)/substance use during pregnancy
o Birth complications (?hypoxic damage)
• Childhood-
o Milestones-
o Childhood illnesses
o Relationship with siblings
o History of trauma
• Education-
o Academic performance ?to what year ?any deterioration
o Bullying
o Hx of suspension/expulsion ?why
o Post school aspirations
• Employment history-
o If many jobs, why have they changed? Fired?
o Training/qualifications
• Relationship history
o Quality of relationships? Able to form longer attachments?
o Friendship groups ?still in contact
MEDICAL HISTORY:
• Allergies
• Prescription medications
• Any associated legal, financial, social, health problems
• Personal history of:
o Thyroid disease
o Head injuries
o Seizure disorders
o Chronic pain/chronic illness
o Cardiac history
▪ Some conditions have cardiac and mental health associations
FAMILY HISTORY:
• Genogram sometimes helps
• Mental illness, suicide attempts, cardiac disease, diabetes, seizures, substance use, thyroid, psychiatric illnesses
SUBSTANCE USE HISTORY:
• Alcohol
o First use
o Current use (type, amount, frequency)
o Prior attempts to cease
o Hx of tolerance
o Hx of withdrawal symptoms, including of seizures
o Progression of use over time
o Previous history of treatment or abstinence
Marijuana/THC
• Other illicits
• ?IVDU
• Recreational drugs: what, when, how long, amount per week
FORENSIC HISTORY
• Current charges
o Violence
o Drugs
• Prior incarceration – history of lengths of sentences and when last released
• Juvenile history
COLLATERAL HISTORY
• OBTAIN CONSENT
• Often a very significant part of an evaluation for patients who are unable to give a coherent self-account or those who may be concealing information that would change your opinion or management
• Often needed prior to formulating risk/devising a mx approach
• When gathering collateral it is useful to see the patient and collateral provider together and alone
Describe key features of psychiatric physical assessment? What systems etc.
• What are potential signs on examination of medical conditions masquerading as a mental illness?
• Are there any conditions that may complicate management?
o E.g. pregnancy, renal failure, hepatic failure, Parkinson’s disease
• Is there evidence of side effects from prescribed medication? Is there evidence of drug intoxication?
TARGETED PHYSICAL EXAMINATION:
• Vital signs
• Height, weight and waist circumference
• General physical
• Cardiac: Especially if commencing an antidepressant or antipsychotic that can affect heart
• Neurological: Extra-pyramidal side effects
• Thyroid examination
Outline what is a psychiatric formulation? Bio/pyscho/social
Outline basic pyshcotic disorders
What is pyschosis/ pyschotic disroders? What are the different types, and how do we diagnose them?
Describe mood disorders?
1) Depressive disorders
2) Mania/Hypomaina/depressive episodes - bipolar disorder
3) substance induced
Outline major anxiety disorders, and how they are diagnosed?
1) Specific phobias
2) scoial anxiety disorders (social anxiety( fear of negative apprasiakl in social setting
2) panic disorders
4) agoraphobia- fear associated with being in a places wher escape is difficult (frequently shops )
5) generalized anxiety disorders - worrrying zabout a variety of a events or situations
also - two other chapters related to anxiety-
somatic symptoms relatred to phyiscal disroders.
OCD and related disorders
OUtline trauma and stres related disorders? PTSD , acute stress disorder etc.
Post traumatic stress disorder:
1) stressors,
2) intrusive symptoms,
3) avoidance
4) negative alterations in cognitios and mood
5) alterations in arousal and reactivity
Duration- symptoms last for more than 1 month
Acute stress disorder- Less than a month
adjustment disorder- Prolonged responses to difficult events
Describe Eating disorders? Types and features.
Anorexia nervosa:
1) restriction of intake
2) below expected body weight
3) cognitive symptoms- belief of being overweight, fear of being fat
Bullmisa nervosa:
1) Binge- compensation cycle
2) compensation- vommitting, laxatives, diuretics, restriction, excercise
Binge eating disorder:
1)
Describe substance related and addicitve disorders - Substance,
Alcohol, caffiene, hallucingenic, ihlanet, opiod, stimulant
- Increased use, craviongs, feeling of loss of control
- tolerance, and possible withdrawl symptoms.
- Interference with functions including work and relationships
- Use despite knowledge of being harmful/a problem
- Excessive amount of time, spent, obtaining and or recovering from substance use
Gambling disorber
Internet Gaming disorder
Outline the 3 subtypes of personality disorders
Cluser A personality disorder
Cluster B personality disorders
Cluster C personality Disorders
What is a personality disorder?
Personally describe ways of thinking, feeling and behaving.
- Personality traits are inherited and or develop in response to early experiecnes and environment
- personality are usually stable across time
- We all have personality traits that can be unhelpful at time- Perfectionism (not good for you all the time)
- Personality disorder is describved when these pervasicve ways of thinking, feeling and behaving Cause distress or problems in your functioning, relationships and goal functioning
Describe borderline personality disorder?
Stigmatized diagnosis
Very strong association with early adverse experience, high incidence of childhood sexual abuse
Repsonses to early trauama influences BPD
Outline delirum vs dementia - What diagnositic features are needed for both (onset, precipitating factors)
What is the Mental health act 2016? Key points?
- Provide for the involuntary assessment and treatement
- Safeguarding patients right and their freedoms
- Balancing their rights and freedoms of others persons
MHA legislation is designed to protect and provide checks and balnces to the powers of detention (rather than greater focus on the legal power to date)
QLD MHA 2016
- Patients must lack capacity to consent to treatement (if they have capacity you cannot detain under MHA)
- Emphasises commmunity treatment
- Emphasises the patient outcome
What decides capacity and descision making regarding a pts capacity? How to test capacity? Insight?
Always presume an adult has capacity.
Capacity is descision and time specific.
General test for capacity: adult must be capable of:
- Understanding the nature of effect of descisions about the matter -> Understand and weigh the consequences of different options
- Freeling and voluntarily making descisions about the matter
- communicating the descision in some way (communication may need to supported or optimised)
What are the different types of authroities?
What are the treamtent criteria? for MH act (authority)
What do you need to do when someone does not have capacity?
Legal requirements! All adults are assumed to have capacity - the onus is on the clinicans
Supported descison making: Presence of support person
Outline exmaination types examination under the mental health act e.g Examination authority etc.
Examination Authority
An application may be made to the Mental Health Review Tribunal for an Examination Authority where all reasonable efforts have been made to engage a person in a voluntary examination of their mental health and there is, or may be, serious risk of harm or worsening health.
An application to the Tribunal may be made by: an authorised person at an authorised mental health service (AMHS), or a concerned person family member friend colleague, or other member of the community who has concerns about the person. If made by a concerned person, a written statement by a doctor (e.g. general practitioner) or authorised mental health practitioner (of an AMHS) is required with the application.
The Examination Authority authorises a doctor or authorised mental health practitioner to examine the person to determine whether a Recommendation for Assessment should be made.
The Examination Authority is valid for seven days for the examination to occur.
The examination may occur in the person’s home or the person may be transferred to an authorised mental health service.
Outline Emergencyexamination authority (MHA)? Reasons, when, who?
Examination The involuntary process usually commences with a Recommendation for Assessment however, in some circumstances, the Recommendation for Assessment is preceded by an examination authorised under another process such as an:
Examination Authority or an Emergency Examination Authority.
Examination Authority An application may be made to the Mental Health Review Tribunal for an Examination Authority where all reasonable efforts have been made to engage a person in a voluntary examination of their mental health and there is, or may be, serious risk of harm or worsening health. A
An application to the Tribunal may be made by: an authorised person at an authorised mental health service (AMHS), or a concerned person family member friend colleague, or other member of the community who has concerns about the person. If made by a concerned person, a written statement by a doctor (e.g. general practitioner) or authorised mental health practitioner (of an AMHS) is required with the application. The Examination Authority authorises a doctor or authorised mental health practitioner to examine the person to determine whether a Recommendation for Assessment should be made. The Examination Authority is valid for seven days for the examination to occur. The examination may occur in the person’s home or the person may be transferred to an authorised mental health service. Policy: Examination authorities Fact sheet: Examination authorities Form: Application for Examination Authority - Available from the MHRT website Form: Outcome of Examination Under an Examination
Emergency Examination Authority In emergency circumstances, a police or ambulance officer can make an Emergency Examination Authority (EEA) if the officer believes a person is at immediate risk of serious harm, such as threatening suicide, and the risk appears to be the result of a major disturbance in the person’s mental capacity.
This could be caused by an illness, disability, an injury, intoxication or any other reason. There is no presumption that the person subject to the EEA has an underlying mental illness.
For this reason, an EEA is made under the Public Health Act 2005. This ensures that the Mental Health Act captures only those persons within its intended scope and that appropriate treatment and care is provided following an examination.
What is the point of the assessment under and examination authority? What is the purpose of this? What is a RA? TA?
Assessment :
When considering involuntary mental health treatment for a person, the clinician must be satisfied that all treatment criteria are met and there is no less restrictive way for the person to receive treatment for their mental illness, for example, there is no Advance Health Directive or substitute decision maker available.
In this case a Recommendation for Assessment can be made by the doctor or authorised mental health practitioner who completed the initial mental health examination.
Recommendation for Assessment
The purpose of the assessment is to decide whether a Treatment Authority should be made so that the necessary treatment and care can be provided to the person during the period when they do not have capacity to consent to the treatment. Wherever possible, mental health assessments and treatment are provided in the community and preferably in the person’s home.