Psych

Question 1

Psych Hx Checklist

Answer 1

1) PC
2) HPC
Incl important symptoms:
- Mood
- Appetite
- Weight
- Sleep
- Energy
- Hallucinations
- Concentration/memory
3) Past psychiatric Hx - seen psychiatrist? been diagnosed with anything? had any medication or treatment?
4) Past medical Hx
5) Family Hx (psych or medical)
6) Personal Hx
- Problems during pregnancy, labour, birth?
- Illnesses as a child?
- School - enjoy it? problems making friends? ever expelled from school?
- Qualifications when left school? Jobs?
- Relationships
7) Social Hx
- Who living with? where living? Current job? benefits?
8) Smoking, ETOH, other recreational drugs
9) Forensic Hx
- Ever in trouble with police, ever convicted of anything?
10) Premorbid personality?
- When did this all start? When did you last feel normal/well? How would you describe yourself before this? How would others have described you
RISK ASSESSMENT (On another card)

Question 2

Risk Assessment

Answer 2

1) Risk to self (deliberate)
- Negative feelings (hopeless, helpless, worthless)
- Ever felt life wasn’t worth living?
- Felt like not wanting to wake up in the morning?
- Ever self harmed before? Attempted suicide?
- Thought? Intent? Plan? (3/2/1 = high/moderate/low risk)
- What prevents you from ending your life?
2) Risk to self (not deliberate)
- Pressure sores, dehydration, malnutrition
- Medications, falls, accidental fires, self neglect, dementia
- Reckless behaviour (driving, alcohol/drugs, gambling, poor financial decisions)
3) Risk to others (deliberate)
- Seeing others as suffering, wanting to end that
- Believing others are trying to harm you
- Fire/arson/theft
4) Risk to others (not deliberate)
- Gambling, alcohol use, driving
- Do they have children/dependents?
5) Risk from others
- Safeguarding issues, theft, abuse

Question 3

Mental State Examination

Answer 3

Appearance + behaviour, Mood/Affect, Speech, Thought, Perception, Cognition, Insight

Appearance & Behaviour

• Age, Gender, Ethnicity, Occupation
• Dress + self care: Provocative –> disinhibited. Dischevelled –> depression or schizophrenia.
• Manner: Were they inappropriate with you?
• Posture and Movement: Helpful/hostile? Amiable/aggressive? Tense/relaxed/overactive? tardive dyskinesia –> antipsychotic use.
• Easy to build rapport?

Mood & Affect

• Mood: subjectively (report what patient says)
• Affect: objectively (expansive, euthymic, blunted, depressed.

Speech

• Rate, Rhythm, Volume, Tone
• Pressure or poverty of speech
• Were they coherent?

Thought

• Content: Thought insertion, withdrawal, broadcasting?
• Form: Pressure or poverty of thought? Thought blocking? Loosening of Association? Flight of ideas?

Perception
- Overvalued ideas (delusions), hallucinations, illusions Depersonalisation (feeling one’s thoughts aren’t ones own), Derealisation (Feeling one’s surroundings aren’t real)

Cognition

• Orientation: To time, place, person
• Attention: Subjective report. Serial 7s (or count 20-1), spell WORLD backwards
• Memory: Immediate, recent, remote
• Grasp: Current prime minister? current topical events?

Insight

• Do you think you are unwell in any way? mentally unwell?
• If so, what do you think is wrong?
• Do you need any treatment?
• If so, what will make you better?

Also present risk assessment

Question 4

Self harm approach

Answer 4

ABC
Antecedent
-Impulsive or planned (stockpiling pills, steps to avoid discovery)
- Made will/suicide note
- Drugs and/or alcohol
- Psychotic symptoms (e.g. command hallucinations)
Behaviour
- Chosen method of suicide
- Perceived lethality? Actual lethality?
- Drugs and or alcohol at the time
Consequences
- How were they found and brought to hospital?
- Regret about attempt or regret about failure
- Compliance with medical intervention

Question 5

Presenting psych management plan

Answer 5

Confirm diagnosis
- Full Hx and physical examination
- Collateral Hx
- Basic tests to rule out organic disease (FBC, urine dip and urine drug screen)
Location of Rx
- Ideally manage in the community under CMHT or Crisis resolution team (or Early Intervention Service, EIS, if <35)
- However, if high risk, admit first
- Ideally informally, however if not compliant, use section … of Mental Health Act)
Management
- Bio, Psycho, Social approach
- Short term: stabilise patient with [medication/therapy] with the aim of returning them to their state before this acute episode
- Long term: once stabilised, offer (prophylactic?) medication and therapy (CBT, psychodynamic therapy…) with the overall aim of getting to the root of the problem and reintegrating the patient into the community

Question 6

Psych disorder heirarchy (with ICD-10)

Answer 6

Organic disorders (F00-09)
 - F00: Dementia
 - F05: Delirium
Substance use disorders (F10-19)
 - F10: Alcohol use disorder
Psychotic disorders (F20-29)
 - F20: Chronic psychotic disorder
 - F23: Acute psychotic disorder
Mood/Affective disorders (F30-39)
 - F31: bipolar
 - F32: depression
Neurotic disorders (stress/anxiety): (F40-49)
 - F40: phobia
 - F41: panic dosorder (41.1 generalised, 41.2 associated w/depression)
 - F43: Adjustment disorder
 - F44: dissociative disorder
 - F45: unexplained somatic symptoms
 - F48: neurasthenia
Physiological disorders (F50-59)
 - F50: Eating disorder
 - F51: Sleeping disorder
 - F52: Sexual disorder
Personality disorder (F60-69)
Developmental disorders (F70-79)
 - F70: Mental retardation
Disorders of childhood (F90-99)
 - F90: Hyperkinetic disorder
 - F91: Conduct disorder
 - F98: Enuresis

Question 7

Dementia vs Delirium

Answer 7

Onset: acute vs gradual
Duration: hours to weeks vs months+
Course: Sudden vs gradual
Altered consciousness: Yes vs No
Hallucinations: Yes vs only if severe
Altered sleep/wake cycle: Yes vs No

Question 8

Differential diagnosis for dementia/delirium

Answer 8

Fall Hx: Subdural haematoma
Incontinence: Normal pressure hydrocephalus
Sexual Hx: HIV and/or syphillis
Vascular Hx: Vascular dementia
Family Hx: Huntington’s
Rapidly fluctuating symptoms: Lewy-body dementia

Question 9

Assessing cognition

Answer 9

AMTS: 10Qs, could be asked to do in the exam
1) Age
2) Current time
- [Give an address, e.g. 42 West Street]
3) Current location
4) Current year
5) Recognise 2 people
6) DOB
7) Dates of e.g. WW2
8) Current Prime Minister
9) Count from 20 to 1
10) Recall address
MMSE: Score out of 30, template given in exam
Addenbrooke’s cognitive assessment: Score out of 100, picks things up sooner but takes around 15 mins
Frontal lobe testing
- Verbal fluency: name as many words beginning with A in 60s (>10 is OK)
- Cognitive estimates: Educated guessing. e.g. “how many camels are there in Holland?” or “how tall is the average woman”
- Abstract reasoning: explain a proverb, e.g. “let the cat out of the bag”
Depression screening (DQ2, DQ9, Hamilton score): all useful as depression is a common cause of apparent cognitive impairment.

Question 10

Dementia: definition & types

Answer 10

Definition: Disorder of 5 As

• Anterograde amnesia
• Agnosia
• Apraxia
• Aphasia
• Executive function (abstract reasoning)

Types:
Alzheimer’s
- Most common
- Insidious onset memory loss, distant memories relatively well preserved
- Apathy, occasional depression and paranoid features
- Risk factors: Age, low IQ, FHx, Down’s, previous mental health issues (>1 major depressive episode), previous head trauma
Vascular dementia
- Insidious onset (ischaemic) or step-wise progression (multi-infarct)
- Known vascular Hx or disease
- See changes on CT or MRI unlike Alzheimers
Pick’s disease
- Disinhibition and severe mood lability
Lewy-body dementia
- Motor symptoms of Parkinson’s
- Visual hallucinations and fluctuating consciousness
- Dx is important, severe sensitivity to antipsychotics

Question 11

Dementia: Investigations and managememt

Answer 11

Dementia screen:

• Blood (U&E, LFT, TFT, FBC, B12, Folate, CRP, Calcium)
• Full neuro exam and more detailed cognitive assessment (MMSE or Addenbrooke)
• Urinalysis (UTI, drugs)
• Syphillis serology, antibody screen, CT scan, serum cholesterol

Management:

• MDT approach, involve family and carers
• Refer to memory clinic
• Alzheimers: If MMSE 10-20: Give donezipil (cholinesterase inhibitor), 6/12 follow up: 1/3 benefit, 1/3 somewhat improve, 1/3 bad side effects

Question 12

Delirium: Definition and symptoms

Answer 12

Definition: Acute clouding of consciousness –> acute confusional state
Symptoms:
- Clouding of consciousness and reduced awareness of surroundings
- Impaired cognition
- Disorientation to time, place, person
- Hallucinations
- Varied rate of speech
- Psychomotor: rapid, random shifts between hypo and hyperactivity
- Sleep wake cycle disturbance

Question 13

Delirium: Causes and Management

Answer 13

Causes: DIMTOP
Drugs (Alcohol/analgesia, Beta-blockers, Corticosteroids, Digoxin)
Infection (UTI, pneumonia, meningitis)
Metabolic
Trauma (head)
Oxygen (lack of)
Poisoning

Management

• Treat underlying cause
• Reduce environmental stimulation, help reorientate with a room with lots of clocks, calendars etc
• Antipsychotics/Benzodiazepines are a last resort, used only if at immediate risk to self or others

Question 14

Substance use definitions

Answer 14

Acute intoxication
- reversible physical and mental abnormalities caused directly by use of a given substance
At risk use
- Substance use at levels which, if continues, are likely to cause physical and/or mental harm
Harmful use
- Continued substance use despite evidence of harm caused (often downplayed by user), including physical, mental, social, familial.
Dependence
- Includes physical (biological adaptations to taking the drug) and mental (altered behaviours to support taking the drug)
Withdrawal
- If dependent, patient suffers symptoms due to absence of the drug. Symptoms usually opposite those of acute intoxication (e.g. agitation and insomnia from BDZ withdrawal)

Question 15

Alcohol abuse: screening/diagnosis

Answer 15

CAGE screening questionairre:
- C: Ever felt you should Cut down?
- A: Anyone ever Annoyed you by criticising your drinking?
- G: Ever felt Guilty about your drinking
- E: Ever had an Eye opener?
- Score of 2 or more raises concerns
AUDIT is a more detailed questionairre for alcohol abuse
Longitudinal approach: When was your first drink? When did you realise it was a problem? Previous efforts to cut down?
Cross sectional approach: Current effects of drinking (physical, mental, social (jobs/relationships, police))?
CIWA-Ar is a tool to formally assess alcohol withdrawal. Around 50% of alcoholics get clinical symptoms of withdrawal.

Question 16

Alcohol abuse: management and complications

Answer 16

Management of alcoholic patients in hospital
- 3/7 IV Pabrinex (multivitamin, including B1 (thiamine)) and reducing BDZ regimen (chlordiazepoxide)
Detox managed in community by specialists, unless:
- Previous failed attempts to detox
- Vulnerable or poor social circumstances (e.g. alcoholic partner)
- Vulnerable people at home (e.g. kids)
- Previous seizures from withdrawal
Complications
- Wernicke’s encephalopathy: due to lack of B1. Causes Ataxia, Nystagmus, Ophthalmoplegia, acute confusional state
- Korsakff’s psychosis: develops from long standing Korsakoff’s. Causes anterograde amnesia and confabulation

Question 17

Schizophrenia: Symptoms/ICD-10 diagnosis

Answer 17

At least one of these (Schneider’s first rank symptoms)
- Thought insertion/broadcasting/withdrawal/echo
- Bizarre delusions
- Auditory hallucinations (usually 3rd person, running commentary, coming from within the body)
- Delusions of control, passivity or delusional perceptions
OR at least 2 of these
- Other hallucinations (often associated with fleeting delusions or persistently overvalued ideas)
- Negative symptoms (apathy, poverty of speech/thought, Inappropriate/blunted affect)
- Thought disorganisation (loosening of association, flight of ideas)
- Change in personal behaviour (loss of interest, aimlessness, social exclusion)
- Catatonic symptoms
Must have been present for at least 4 weeks

Question 18

Schizophrenia: definitions and types

Answer 18

Perceptual disturbances:
- Hallucination (perception without stimulus) vs illusion (incorrect perception of real stimulus)
- Hallucinations: Visual (often organic), Auditory (1st, 2nd, 3rd person), Gustatory, tactile, somatic
Thought disorder
- Delusion: unshakeable belief despite clear proof to the contrary. E.g. nihilistic, control, grandiose, persecution
- Overvalued idea: plausible, fairly sound explanation but patient is obsessed with it
Types of schizophrenia
- Paranoid: mostly positive symptoms (hallucinations, delusions), better prognosis
- Hebephrenic: disorganised thoughts. Inappropriate/flat mood/affect. Inappropriate behaviour. Early onset, poor prognosis
- Catatonic:. Waxy flexibility, stiffness. stupor, tics, mannerisms. rare
- Residual. at least a year of mostly negative symptoms preceded by at least one clear cut psychotic episode

Question 19

Schizophrenia: DDx and investigations

Answer 19

DDx:
Organic: Intoxication, Withdrawal, Side Effects (anti-parkinsonian), Brain (infarction/neoplasm), dementia, delirium, epilepsy
Psychotic: Acute psychotic episode, Schizoaffective disorder, delusional disorder
Mood: Bipolar with psychosis, Depression with psychosis
Personality disorder: Schizoid, paranoid, borderline, schizotypal

Investigations

• Full collateral Hx (work, relationships, finances) and examination
• FBC (important for clozapine (agranulocytosis))
• U&E, LFT (renal and liver function help choose drug)
• TFT, ESR, syphillis serology (rule out organic causes)
• CT/MRI: Rule out brain infarct or neoplasia
• ECG: Antipsychotics can cause prolonged QT
• EEG/CT - rule out epilepsy/brain tumour

Question 20

Schizophrenia: management

Answer 20

Setting:

• Hospital acutely to stabilise the patient (esp if psychotic and risk to others or self)
• Community once stable (OPD, care coordinator) to manage and prevent relapse

Bio:
- BDZ to calm an acutely agitated or aggressive patient, esp if immediate risk to self or others
- ECT to treat acute, severe catatonic symptoms
- Antipsychotics (can give 2-4 weekly depot injections if compliance is likely to be an issue)
- typical (haloperidone) cause extra-pyramidal side effects (tardive dyskinesia, neuroleptic malignant syndrome (fever, acute confusional state, rigidity, autonomic dysfunction))
- atypical (olanzipine, respiridone) cause weight gain, hyperlipidaemia, diabetes
- Clozapine is used after 2 drugs (at least one atypical) has failed, for treatment resistant schizophrenia. Can cause agranulocytosis.
Psycho:
- CBT: challenge delusions, help come to terms with illness
- Family therapy: Prevent relapse
Social:
- Appoint care coordinator in community: Check mental status regularly and provide rapid access to treatment when needed
- Rehabilitation: Social skills, daytime activities, help with benefits, employment. Aim to reintegrate with comunity.

Question 21

Depression: assessment and symptoms

Answer 21

Assessment:
PHQ2:
- Have you felt hopeless or depressed in the last month?
- Have you experienced little joy in doing things in the past month?
- If yes to either, ask if they would like help. If so:
- GP: PHQ9 (Patient Health Questionnaire for depression)
- Hospital: HADS (Hospital Anxiety and Depression Scale)
Core symptoms
- Low mood, Anergia, Anhedonia
Associated symptoms
- Poor sleep
- Poor concentration and indecisiveness
- Poor or increased appetite
- Poor self confidence
- Poor libido
- Guilt
- Psychotic symptoms
- Agitation or Slowed movements
- Suicidal thoughts or acts
Diagnosis:
- Subthreshold: 1 or 0 core symptom or <2 weeks
- Mild: 2 core and 2 associated symptoms, >2weeks
- Moderate: 2 core and associated symptoms, >2weeks
- Severe: 3 core and 4 associated OR psychosis, >2weeks

Question 22

Depression: Management

Answer 22

Location:

• Acute: risk assess and decide whether to admit
• Long term: manage in community

Bio
Antidepressants
- NOT recommended for acute mild depression
- recommended for dysthymia, persistent mild depression, moderate-severe depression or any depression with a Hx of severe depression
- SSRIs (Fluoxetine, sertraline): currently first line, relatively safe in OD. Inhibit 5-HT reuptake, little effect on NA or DA. SE: nausea, vomiting, diarrhoea, headaches. Tolerance usually builds up in 7-10 days. Can cause GI bleeds (esp in elderly) and increased risk of suicide.
- TCAs (Amytryptiline, Nortryptiline): Inhibit reuptake of 5-HT and Na and DA. SE: sedation, anticholinergic (dry mouth, blurred vision, urinary retention, constipation), cardiotoxic (long QT, ST elevation), discontinuation syndrome (nausea, ataxia, more dreams). Can cause switch to mania in bipolar patients.
ECT: Used in severe depression, often as a last resort, e.g. concerns about not eating

Psycho: CBT: for mild: support, education, problem solving. Monitor for severe depression
Social: Self help books/websites (mild), support groups

Question 23

Mania: Symptoms

Answer 23

Elevated or irritable mood + at least 3 of the following for at least a week
- Increased energy (reduced need for sleep, racing thoughts, flight of ideas, overactivity)
- Increased ambition
- Increased sex drive (with whom?)
- Increased spending (how do they afford it)
- Delusions of grandeur
- Increased use of drugs or alcohol
- Reduced attention span
Also ask
- Past psych Hx (e.g. depression), compliance to psych meds
- Forensic Hx

Question 24

Bipolar: Types and management

Answer 24

Bio (Acute)
- Antipsychotic if acutely manic or behavioural disturbances due to mania
- Lithium or valproate if patient has responded to these before and is compliant
- Lithium only if less severe, as it has a slower onset of action
- BDZ if agitated++
Bio (long term)
- Lithium or valproate. Don’t use valproate in women of childbearing age. Consider patient wishes
Psycho: CBT to challenge delusions, come to terms with illness/ Family therapy to avoid relapse
Social: Appoint care coordinator to monitor and provide rapid clinic access if needed

Question 25

Anxiety disorder: Screening and types

Answer 25

Relatively common, 12-17% 1yr prevalence, more common in women
Screening
- GAD2 (first 2 qs of GAD7) picks up a lot ( 1-feeling nervous, anxious, on edge all the time?? 2-Can’t control or stop worrying? 0=never, 3=all the time)
Types
Generalised anxiety disorder
- Anxious for at least 6 days a week
- Autonomic hyperarousal
- Apprehension
- Motor hyperactivity (can’t relax)
Paroxysmal anxiety: discrete <1hr episodes of autonomic arrousal
- Unknown trigger: random panic attacks. 95% have agoraphoia
- Known trigger: e.g. phobias (spiders), agoraphobia, fear of social scruitiny
- Check for organic causes (thyrotoxicosis, ETOH/opiate/BDZ withdrawal)
Other forms:
- secondary to stress e.g. PTSD, adjustment disorder
- Secondary to OCD:
- Obsession: Recurrent, invasive thought, upsetting. patient has insight
- Compulsion: Ritual that needs to be done to avoid disaster. Not doing will increase anxiety but ritual isn’t pleasant
- Laasts >2 weeks, pt has insight but cannot resist the ritual. Affects function. 2/3 will have a depressive episode

Question 26

Anxiety disorder: management

Answer 26

Bio (acute)
- BDZ can calm an acutely severely anxious patient
Bio (long term)
- SSRIs (fluoxetine/sertraline) or MAOIs (e.g. phenelzine) can help with generalised social anxiety
- beta blockers (e.g. labetalol) can help with specific social anxiety (performance anxiety)
- Rapid Eye Movement therapy for PTSD
Psycho
- CBT helps prevent relapse, either in groups or individual
- Contains some element of anxiety management and relaxation training

Question 27

Eating disorders: Definition and history

Answer 27

Definition: Determined, conscious effort to lose weight due to overvalued ideas or dread of being overweight
History
- How do you feel about your weight
- Calculate their BMI, ask about their ideal weight
- Efforts to lose weight (Vomiting, Laxatives, drugs, exercise)
- Describe typical day’s eating
- Binging
- Depression screen (DHQ2), prev psych Hx
- Physical symptoms (amenorrhoea, acid reflux, constipation)
SCOFF questionairre:
- Ever make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you ever lost One stone in a 3 month period?
- Do you consider yourself Fat whilst others complain you are too thin?
- Does Food dominate your life?

Question 28

Eating disorders: types

Answer 28

Anoexia (ICD-10, need all 4)
- BMI <17.5 or 15% less than ideal
- Distorted body image (dread of being fat)
- Deliberate attempts to lose weight (drugs, laxatives, vomiting, exercise)
- Endocrine disturbance (low T3, high GH and cortisol, amenorrhoea, delayed puberty)
Bulimia (ICD-10, need all 4) - 1/2 have prev Hx of anorexia
- BMI >17.5
- Distorted body image (dread of being fat)
- Binging/loss of control
- Measures to counter weight gain (fasting, exercise, laxatives etc)

Question 29

Eating disorders: Management

Answer 29

When to admit?
- BMI <13.5 or rapid weight loss
- Syncope
- Severe electrolyte imbalance
- Social crisis or risk of suicide
NB: MHA can be used to give IV or NG feeds if lack of eating is likely to cause death, e.g. low potassium –> arrhythmia
Bio:
- Fluoxetine. Imprives weight gain and prevents relapse
Psycho:
- Psychoeducation about ideal weight
- CBT: explore issues of low self esteem, perfectionism, control issues
- Psychodynamic psychotherapy
Social
- Nutritional management: Negotiate target weight. Meal plans. Shopping and cooking skills

Question 30

Childbirth associated disorders: history

Answer 30

• Main features of this pregnancy
• RISK ASSESS (ask explicitly if the thought of harming herself or the baby has crossed her mind)
• Previous pregnancies and any associated problemt
• Previous psych history
• Good social support around her?
• Any delusional ideas

Question 31

Childhood associated disorders: symptoms and Rx

Answer 31

Baby blues

• Common, 3 days after pregnancy, affects around 50% of women
• Labile mood, tearful, anxious
• Resolves spontaneously

Post natal depression

• 2-3 weeks after delivery. Affects 10% of women
• Core symptoms (anergia, low mood, anhedonia), biological symptoms, suicidal ideation
• Risk factors; poor social support, external stress, previous depression
• Rx:
• Bio: antidepressants, ECT
• Psycho: Therapy groups, counselling

Puerpural psychosis

• 3-4 weeks post natal, affects 0.2% of women, DANGEROUS
• Hallucinations, delusions, psychosis, mood swings, confusion
• Risk factors: First baby, C-section, previous uni- or bipolar depression
• Rx: Location: Admit to mother and baby ward
• Bio: Antidepressants, anti-psychotics, ECT
• Psycho: CBT, focus on challenging delusions as with schizophrenia
• Social: Support father

Question 32

Personality disorders: types

Answer 32

Cluster A: (Mad) Odd/eccentric
- Schizoid PD: emotionaly cold
- Paranoid PD: paranoid, suspicious
- Schizotypal PD: Eccentric (magical thinking)
Cluster B: (Bad) Dramatic/emotional/erratic
- Narcissistic PD: Grandiose delusions of self importance
- Histrionic PD: Exaggerated displays of emotion
- Borderline PD: Intense, unstable relationships
- Antisocial PD: Recurrent aggressive, antisocial behaviour
Cluster C: (Sad) Anxious/fearful
- Obsessive Compulsive (Anankastic) PD: Obsessed with order and perfection and control
- Dependent PD: Excessive need to be cared for
- Avoidant/anxious PD: Fearful of inadequacy

Question 33

Mental capacity act: Principles and options when someone lacks capacity

Answer 33

Principles
- Anyone over 16 is presumed to have capacity
- Mental illness DOES NOT EQUAL lack of capacity
- Capacity is judged individually for each decision
- Clinician must make maximal effort to assist patient’s capacity, e.g. interpreters, learning difficulty specialsits
Criteria for capacity
- Patient must be able to 1) understand the information, 2) retain the information, 3) weigh up the information to make a decision and 4) communicate the decision back
- “unwise” decisions do not mean lack of capacity

If someone lacks capacty
- Act in best interests of the patient, taking into account what the patient would have wanted, and opinions of family and carers etc
- Always choose the least restrictive option where possible
Advance directives
- Made when patient has capacity. Can refuse treatment. Must explicitly state if this applies in life threatening situation. Cannot be used to request Rx.
Lasting power of attourney
- Appointed by patient when they have capacity, comes into effect when the patient loses capacity. Registered in the office of public guardian

Question 34

DOLS and Mental Health Act

Answer 34

DOLS - Deprivation Of Liberty Safeguard (part of MCA)

• Process to regulate deprivation of liberty (e.g. care home, psych ward), to care for those with learning difficulties especially
• Patient must have a representative
• Patient has right to challenge the deprivation of their liberty
• Provides mechanism to review DoL regularly to ensure it isn’t being abused

Mental health act
- Can be used to detain patients for mental health assessment or treatment
- Patient must have a mental health condition (excluding learning difficulties, ETOH/drug disorder, sexual preference disorder)
- Severity/nature of condition warrants admission
- Patient is at risk to themselves or others’ health and safety
- Patient is unwilling to be admitted informally
Sections
- Section 2 (assessment): done by AMHP, approved by 2 doctors, lasts 28 days. done for MH assessment
- Section 3 (treatment): as above but last 6 months, used for treatment, can be renewed
- Section 4: Needs 1 doctor, admit patient from community, lasts 72hrs
- Section 5(2): Needs 1 doctor, admit patient from hospital (inpatient), lasts 72hrs
- Section 5(4): Done by MH nurse if no doctor is present. Admit from inpatient. lasts 6 hours
- Section 136: done by police to bring somebody from the community to a place of safety, lasts 72hrs
- Section 135: as above but bring patient from their home (more paperwork involved)

Question 35

Mental Health Act: other rules/pt rights

Answer 35

Other stuff

• Patient has right to review of section 2 within 24 days of starting or section 3 within 6 months of starting or renewal
• Any changes to treatment under section 3 must be agreed to by the patient or the SOAD (Second Opinion Appointed Doctor)
• Responsible Clinician (RC) can appoint leave
• Discharge can only happen if RC discharges patient, or the section 3 expires
• May be discharged under CTO (Community treatment order), where patient must adhere to treatment and be available for assessment by doctors of be brought back to hospital
• MHA does NOT allow for treatment of unrelated physical health conditions