Psychiatric Exam, Risk, and the Law

Question 1

Describe risk to self

Answer 1

Risk cannot be eliminated

It can be rigorously assessed and managed

Risk is dynamic, therefore risk assessent needs to be frequently reviewed

3/4 are men, they tend to use violence whereas women take overdoses and are therefore more likely to be saved. The 40-44 age range is most at risk

Suicude: A fatal act of self injury, undertaken with more or less conscious self-destructive intent, however vague and ambiguous

Para suicide: Similar to suicide but for whatever reason the victim survived the attempt

Deliberate self harm: An act where the action was not with the intention of death, but to cause harm

75% of suicide victims had contact with GP within year of suicide 45% within one month. 33% had contact with mental health services.

Question 2

What are the clinical variables for suicide?

Answer 2

Inpatient Risk highest during inpatient stay and 14 days post-discharge.

Risk Increased with forensic history, previous suicidal behaviour, violence to property, recent bereavement and presence of delusions.

Post discharge
Unplanned discharge, lack of continuity of care, unemployment, suicidal behaviour prior to admission.

Identified risk factors? — being male, living alone, unemployment, drug and alcohol misuse, mental illness, past self harm

Mood disorders e.g. depression
Greater severity of illness, self neglect, hopelessness, ipaired concentration, alcohol abuse, hostory of suicidal behaviour

Schizophrenia
Postive psychotic symptoms, Post psychotic depression, Young and Male, First Decade of Illness, Relapsing Pattern of Illness, Recent Discharge from Hospital, Social Isolation, Good insight into illness

Alcohol abuse
Male sex, longer duration, single, multiple substance abuse, comorbid depression

Personality Disorder
Nearly always associated with depressive syndrome or substance abuse. Borderline at highest risk

Chronic Physical Illness
• Increased risk in patients with chronic neurological, gastro-intestinal, cardiovascular disorders, cancers.
• Severe chronic pain leads to increased risk-depression.
• Disfigurement, especially in women
• Chronic physical illness can lead to limitations
including loss of job, role, family, money, etc

Question 3

Describe deliberate self harm and what is associated with it?

Answer 3

The behaviour is self initiated and harm is intended but the intention to kill is low

Two main types - self-poisoning, self-injury

Many attendances in A&E. Higher rates in females. Peak age 15-44yrs.
Risk of suicide within one year is 0.7% males and 0.5% females.

Associations with repeated self-harm?

• Previous self-harm/ psychiatric contact
• Alcohol / Drug misuse
• Unemployment/ Social class
• H/o trauma, sexual or physical abuse
• Criminal record/ history of violence
• Single / divorced / separated
• Family history- 4 fold increase risk, twin and adoption studies

Question 4

What reasoning underlies DSH?

Answer 4

• Motivation Wish to die, cry for help, communication with others, unbearable symptoms
• Psychological characteristics Impulsivity, cognitive rigidity, problem-solving deficits, hopelessness
• Coping mechanism Temporary relief of anxiety, stress, emotional numbness, sense of failure

Substance Abuse and DSH
• Extensive use at time of DSH or just before : 40-75% males & 12-50% females.

• Use of alcohol can add to the potential dangers of an OD
• Alcohol increases the toxicity of psychotropic drugs
• Alcohol alone can lead to unconsciousness and therefore delay time to treatment

Question 5

What goes in a risk assessment

Answer 5

History:
Triggers
Preperation - longer preperation is worrying
Circumstances
After the act

What lead up to it?
Depression? Schizophrenia? Personality Disorder

What about now?
Ideation
Intent
Plans

Treat the psychiatric disorder

Question 6

What factors go into risk to others?

Answer 6

More than 2/3 of victims are male
Over 50% of male and 75% of female are known to their killers
As in previous years, children under one year old had the highest victimisation rate

In child protection: think about differen types of abuse: sexual, emotional, neglect, physical

Antisocial personality disorder, alcohol/drug misuse, Schizophrenia: cause a small increased risk to other but not affective disorders

In psychotic disorders risk is increased by

• Specific persecutory delusions or hallucinations
• Command auditory hallucinations
• Has the risk been modified by treatment?
• Relevance of premorbid personality, substance misuse, alcohol?
• MDT views similar to your own
• Circumstances of previous violent behaviour
• Potential victims
• Aftercare—ongoing treatment and support

Question 7

What is the basic structure of the psychiatric history?

Answer 7

• *History of presenting complaint:** Start with open questions but can use SQITARS
• *Past psychiatric history:** any admissions or treatment before. Have they had problems and not saught help. Has the treatment been effective?
• *Sociodemographic Details**
• *Past Medical History:** Any comorbidities, general health, risk factors
• *Medication History**
• *Family history:** Mental and Physical
• *Personal History**: Infancy and Early Childhood, adolescence and education, occupational history, sexual development, drugs, forensic

Premorbid Personality: What were they like before they were unwell

Mental State Examination: Apperance & Behaviour, Speech, Mood, Thought, Perception, Cognition, Insight

Risk: Risk to self: Do you feel life is worth living? Risk to health (worsening mental or physical illness) Risk to others (paranoid delusions, command hallucinations)

Question 8

What factors go into the personal history

Answer 8

Infancy and Early Childhood
Normal pregnancy
Any time away from family
Developmental Milestones
What was the setup at home and did anything happen within the famaily

Adolescence and Education
Where did they go to school
Did they have friends
Did they have higher education? Did relationships change
How did they do academically​

Occupational record
What jobs have they done
Did they hold down one job or move a lot

Sexual Development
When was their first relationship
Have they been in lots or few
Have they been abusive of supportive
Are there any themes in the relationships

Alcohol/Drugs
Do they use, is there evidence of dependance

Forensic
Any contact with the police

Question 9

Discuss apperance and behaviour in the MME

Answer 9

Appearance and Behaviour
— Well kempt? Unkempt? Clothing, e.g. casual, flamboyant, formal?
— Eye contact, appropriate, sustained? Intense?, Reduced, avoidant?
— Level of rapport e.g. easy/quick to develop, frosty, guarded?
— Psychomotor retardation (significant slowing of speech and body movements)
— Psychomotor agitation (noticeable and marked increase in body movements; eg hand wringing, pacing)
— Distracted, responding to unseen stimuli

Question 10

Discuss speech in the MME

Answer 10

Speech
• Comment on Rate, Rhythm and volume/tone. State if normal.

• Any evidence of Formal thought disorder?
— Circumstantiality, tangential, loosening of associations, word salad, neologisms, flight of ideas
• Normal — `No evidence of formal thought disorder’

Question 11

Discuss mood in the MME

Answer 11

• Subjective — How do they describe their mood? — Can use a mood scale?

• Objective — E.g. Low mood, expansive mood (enthusiastic and excitable), Euphoric mood. Euthymic (‘normal’}.
— Describe their ‘Affect’ (emotional responsiveness: refers to immediate expressions c.f. mood over a longer period)
— blunted- decrease in amplitude of emotional expression
— Flat - virtually complete absence of affective expression
— inappropriate - emotions expressed are not congruent with content of patient’s thoughts e.g. laughing about sad things
— labile - unpredictable shifts in emotional state

Question 12

Discuss thought in the MME

Answer 12

• Form (important to you diagnostically)
— Delusion (persecutory, grandiose, nihilistic, etc.)
— Over-valued idea, paranoid ideation
— Obsessive rumination
— Obsessive intrusive thought
— Phobia

Content (important to the patient I)
— That the thought relates to, e.g. thought that ‘spouse is cheating (content) could be delusion, obsessive intrusive thought, paranoid ideation, etc.

Question 13

Discuss perception in the MME

Answer 13

• Illusion- misinterpretation of a sensory stimulus that can occur in any sensory modality (e.g., misperceiving billowing curtains in a darkened room to be an intruder)
• Hallucination - perceiving a sound, sight, taste, smell or touch in the absence of external sensory stimulation that seem incistinguishable from such an experience in reality.
— 2nd person auditory e.g. you are sick
— 3rd person auditory e.g. We will soon find out where he lives
— Running commentary e.g. he is looking at the door now

• *Depersonalisation** - the sense that one is outside of his or her self.
• *Derealisotion -** vague sense of unreality in one’s perceptic, of thc external world.

Question 14

Discuss cognition and insight in MME

Answer 14

Cognition
Comment on orientation to time, place and person

Various ways of testing dependent on situation e.g AMT, MMSE, ACE-R, MoCA, CAMCOG

Insight
The person’s understanding of their experience
Not normally yes or no
Do they believe they are unwell?
Do they believe they have a mental disorder?
Attitude to treatment

Question 15

Describe what is necessary for consent?

Answer 15

Informed - Appropriate level of information

Competent - Capacity to consent

Voluntary - not coerced by relatives, medics etc

• Consent can be implied
• can be withdrawn - and capacity might be lost
• can be verbal, non verbal or written
• under age 16 may be competent

Question 16

What underlies the idea of best interests

Answer 16

• The patient’s own wishes and values (where these can be ascertained), including any advance decision, spiritual and religious welfare.
• Effectiveness of the proposed treatment, particularly in relation to other options.
• Option is least restrictive of the patient’s future choices.
• The likelihood and extent of any degree of improvement
• The views of the parents, if the patient is a child.

The patient should participate even if lacking in capacity

If patient will regain capacity may be appropriate to wait

The decision makes must ascertain and consider the patients past and present wishes and feelings

Must take into account if both appropriate and practical the next of kin about what the patient is likely to see as beneficial.

Question 17

How do advance decisions work?

Answer 17

Advanced decisions can be made in advance of becoming incapacitated

Only relate to medical treatment

Only in the negative to refuse medical treatment of a specific type

Person must be over 18 and have capacity. Can be altered and withdrawn if they still have capacity.

IF AD have not been make decisions must be taken in the patient’s best interests

Lasting power of atternity - Someone else can legally make decisions but must be nominated at a time when the person had capacity. Can extend to property, welfare. But decisions taken are still subject to the best interests requirement, can go to the Public Guardian if concerned.

Lack of capcity can be temporary or permanent - if possible to defer a decision to await return of capacity then do!

Question 18

What are the principles of the mental capacity act

Answer 18

Presumption of capacity at all times

A new legal right to support individuals in making their own decisions

A right to make unwise decisions

Anything done for people without capacity should be least restictive for their freedom of action

Must be done in their best interests

Assessment should be time and decision specific

If in doubt 2nd opinions, legal opinion, case conference

Question 19

How can capacity be tested, i.e. what are the 4 stages to consider in making a Capacity Assessment

Answer 19

Understand the information

A person is unable to make a decision for himself if he is unable to understand the information relevant to the decision

The assessor needs to decide how much information is essential to make the decision

Time and issue specific

Retain the information

They must be able to retain the information long enough to make the relevant decision (but they can forget it thereafter)

Use or weigh it up

The person should use or weigh the information as part of the process of making a decision. Severe stress can impair capacity e.g. needle phobia

The information must be believed by the patient (Re C).

Communicate the decision

Patient must be able to communicate the decision - but communication vague

Question 20

What are the overriding principle of the mental health act?

Answer 20

Minimise the undesirable effects of mental illness for the individual

Least restrictive way possible

Participation of patient and NoK

Equity, effectiveness and efficiency.

We have tired everything else.

Question 21

Describe section 5 of the MHA

Answer 21

Section 5 (4)

• Power granted to RMNs (responsible medical nurses) to detain an inpatient for up to 6 hours for medical assesment where mental illness is suspected

Section 5 (2)

• The RMO (responsible medical officer - consultant) or nominated deputy can detain an inpatient (ED does not count) for up to 72 hours under the mental health act
• No appeal
• To allow formal mental health act to be completed

Question 22

Describe section 2 of the MHA

Answer 22

Section 2

• 2 doctors — at least 1 of whom should be Section 12(2) approved (psych consultants and regs).
• 1 Approved Mental Health Practitioner — not just SW now
• Community or inpatient (anywhere except prison)
• Section for maximum of 28 days for Assessment (and treatment) of a mental disorder
• Appeal within first 14 days — heard within 7 days by a tribunal. Next of kin can also appeal (rare)

Question 23

Describe a sectio 3

Answer 23

Section 3

• 2 doctors — at least 1 of whom should be Section 12(2) approved
• 1 AMHP — not just SW now
• Community or inpatient (anywhere except prison)
• Section for maximum of 6 months for treatment of a mental disorder
• 1 Appeal to both hospital managers panel and tribunal. But takes a couple of months to put together.
• Can fill out a form for another 6 months. In this case there is an automatic appeal. Some people are under this section for decades

Question 24

Describe sections 135, 136 of the MHA

Answer 24

Section 136

• Police power to remove to a place of safety (police cells should only be for very violent. ED is acceptable) from a public place (home is safe) for an assessment by an AMHP and 1 doctor.
• Held up to 72 hours to allow assessment
• Police to stay with person If needed second doctor attends for a MHA assessment for Section 2 or 3

Section 135

Can get a magistrates warrent to allow the police to break the door down to allow access to a property if you have serious concerns

The police can keep you or take you to a ‘place of safety’.

You can be kept on this section for up to 36 hours.

Question 25

Describe a section 17, section 117

What is a CTO

Answer 25

Section 17

Whilst detained in hospital under S2, S3 a patient may have leave under S17 to go outside, home, for several hours, overnight, or longer, if safe to do so.

Section 117

Anyone who has been on section 3 is entitled to S117 aftercare from local authority. So authority will pay for any care you need.

Community Treatment Order

• Patient on S3 can be considered for a CTO
• Patient is well enough to leave hospital but may default from treatment/follow up

Question 26

What are level 1a, 1b, 2 and general observations on the ward?

Answer 26

Observation aims to prevent patients from becoming a risk to themselves or others by being attentive whilst attempting to minimise the extent to which the patient feels he or she is under surveillance.

• Level 3 Observations – minimum of hourly checks
This is the minimum acceptable observation for all inpatients and should include: location of patients, safety, wellbeing, they are not showing any signs of ill health and the consideration of potential risks.

• Level 2 Observation - intermittent observation.
This level of observation requires that the patient should be observed at intermittent intervals. The frequency of these observations will be determined and agreed by the multi-disciplinary team and will be dependent upon the level of risk exhibited by the patient.

• Level 1B Observation – constant observation within Close Proximity
The patient must be in full sight of the nurse at all times, and the nurse needs to be close enough to the patient to enable effective intervention at any time if required.

• Level 1A Observation - constant observation within Arm’s Length
The patient must be in full sight and within arm’s length of the nurse at all times, and the nurse needs to be close enough to the patient to enable effective intervention at any time if required.