Session 01 - Principles of Psychiatry Flashcards
Define mental capacity.
The ability to make your own decisions.
Important as it gives patients autonomy and the right to make choices about their own healthcare, but becomes complicated when people lack capacity.
5 key principles of mental capacity.
1) A person is assumed to have capacity until it is established that the person lacks it.
2) A person should not be treated as unable to decide, unless all practicable steps to help them have failed.
3) A person should not be treated as unable to decide just because it is unwise.
4) Decisions made on behalf of an incapable person must be in their best interests.
5) Regard should be taken to find the solution which is least restrictive of the person’s rights and freedom of action.
S2(1) of the mental capacity act defines a patient lacks capacity if he:
1) has an impairment of the functioning of the mind and brain;
2) and is unable to:
a) understand the information relevant to the decision
b) retain that information
c) use or weigh that information in making the decision
d) communicate the decision made
Under the MCA, there are three justifications for the provision of treatment for an adult who lacks capacity:
1) If a valid advanced decision to refuse treatment exists.
2) If a valid Lasting Power of Attorney for Health and Welfare exists.
3) If neither exists, the person providing the treatment should act in the patient’s best interests.
What is an Advanced Decision to Refuse Treatment (ADRT)?
A decision made by an adult at a time when they have capacity to refuse medical treatment in the future, in the event that they have lost capacity.
An ADRT is not valid if:
- patient withdraws decision at a time when they had capacity
- granted an LPA to someone else
An ADRT is not applicable to the treatment in question if:
- the treatment is not the treatment specified in the AD
- any circumstances specified in the AD are absent
Advanced decisions to refuse life-saving or life-sustaining treatment carry which conditions?
- must be in writing
- must be signed, witness, countersigned
- includes a statement that patient intends the ADRT to be respected even if their life is at risk
If unsure about ADRT, what advise should doctors seek?
Apply to the Court of Protection for clarification.
What is Lasting Powers of Attorney?
A legal document which allows an adult with capacity to nominate an attorney, granting them the legal power to make decisions on their behalf.
What are the types of LPA?
- health and welfare (includes giving or refusing consent to medical treatment)
- finances
If a person without capacity did not grant an LPA, what action can be taken?
The Court of Protection can appoint a ‘personal welfare deputy’ to make the decisions if:
- there is doubt whether decisions will be made in someone’s best interest
- someone needs to be appointed to make decisions about a specific issue
What is a best interest decision?
In the absence of ADRT or LPA, the person providing treatment is responsible and must act in the best interests of the patient.
Is it possible to treat mental disorders if a patient has capacity to make decisions about treatment, and refuses the treatment?
Yes - people who are detained under S2/3 of the Mental Health Act can be given treatment without their consent, as it is necessary for the protection of themselves and others.
Who does the Mental Health Act apply to?
Applies to anyone with a disorder of the mind.
Excludes anyone with dependence on drugs and alcohol, and those with learning disability.
Applies to people of any age (although children are usually treated with the consent of their parent).
S135 of Mental Health Act
a) purpose
b) recommendation
c) duration
a) allows police to enter a house and remove the patient to a place of safety.
b) police officer.
c) 72 hours.
S136 of Mental Health Act
a) purpose
b) recommendation
c) duration
a) allows police to take someone to a place of safety for assessment.
b) police officer.
c) 72 hours.
S5(4) of Mental Health Act
a) purpose
b) recommendation
c) duration
a) allows a nurse to detain an inpatient for assessment when doctor comes.
b) mental health nurse
c) 6 hours
S5(2) of Mental Health Act
a) purpose
b) recommendation
c) duration
a) allows a doctor to detain inpatients for assessment (cannot be used in ED).
b) 1 doctor
c) 72 hours
S4 of Mental Health Act
a) purpose
b) recommendation
c) duration
a) allows a patient to be admitted to a mental health unit and cared for, while arrangement for detention under S2 or S3 are made.
b) 1 doctor who is S12 approved.
c) 72 hours
S2 of Mental Health Act
a) purpose
b) recommendation
c) duration
a) assessment and treatment (non-renewable)
b) 2 doctors
c) 28 days
S3 of Mental Health Act
a) purpose
b) recommendation
c) duration
a) treatment (given for three months without consent, then requires form); renewable after 6 months.
b) 2 doctors
c) 6 months
S63 of Mental Health Act.
“The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering.”
What are the supportive psychotherapies?
Counselling and supportive psychotherapy.
Principles of counselling.
Unstructured sessions allowing the patient to establish rapport, reflect and get reassurance over 6-10 sessions.
It is the least intense level of psychotherapy, used for mild depression and anxiety.
What are the psychodynamic psychotherapies?
Psychoanalysis.
Based on the work of Freud, who theorised that human behaviours are being determined by unconscious forced derived from primitive emotional needs.
Procedure of psychoanalysis.
Patient explores their subconscious by using free association (says whatever is on their mind).
Therapist interprets these statements and link the patient’s past experience with their current life, using two skills:
1) Transference: patient re-experiences strong emotions from early relationships with the therapist.
2) Counter-transference: therapist experiences strong emotions towards the patient.
Problems with psychoanalysis.
- long time needed to work
- very intensive and expensive
- patients are left to work it out themselves
- patients can become dependent
What is cognitive behavioural therapy (CBT)?
Therapy that works on the interplay between thoughts, emotions and behaviour.
It aims to tackle both cognitive thinking and behaviour in mental illness.
What is cognitive analytic therapy?
A short time-limited therapy that provides inexpensive psychological treatment, looking at the way an individual thinks and feels.
The key of this therapy is reflection after.
Principles of cognitive analytic therapy (CAT).
Reformulation phase - establishes where the patient’s psychological problems have developed from.
Diagrams to see how effective their current coping strategies are in feeling with the current problem.
Finds new and better ways of coping, which are more relevant and suitable to their current lives.
What is EMDR?
A type of psychotherapy allowing the patient to access past traumatic memories and emotionally resolve them.
Procedure of EMDR.
Therapist takes a history to establish traumatic memories and the emotions felt at the time.
They then work together to create a positive belief about the event.
The therapist activates both sides of your brain using dual activation stimulation, by making them do eye movements.
This allows the brain to reprocess the upsetting memories by removing the old emotion, and replacing it with the more positive emotion.
What is interpersonal therapy?
Patient explains who their close relationships are to the therapist, allowing them to view the patient’s emotions in terms of their network (e.g. close family may have died causing grief).
The rest of the session then works on coping and changing the view of these events, transforming the relationship to a positive one.
What is family therapy?
The therapist asks questions and observes the family style of interacting with each other.
The therapist then gives feedback and encourages positive engagement.
Used first line in treatment of children with eating disorders.
What is ECT?
Electrodes induce a modified cerebral seizure within the brain, leading to large neurotransmitter release, hormone secretion, and a transient increase in blood brain barrier permeability.
Uses of ECT.
- severe depression
- catatonia
- severe mania
ECT procedure.
- patient NBM
- patient given anaesthetic and muscle relaxant
- preoxygenation to increase SpO2
- a shock is delivered to the scalp, evoking a 20-60s seizure within the brain
Side effects of ECT.
- headache
- short term memory impairment
- retrograde amnesia
- cardiac arrhythmia
Contraindications of ECT.
- raised intracranial pressure (absolute)
- stroke and MI (relative)
Mental State Exam components.
A Brilliant Scientist Makes All Theories Too Perfectly Complicated “In-It”.
Appearance
Behaviour
Speech
Mood
Affect
Thought form
Thought content
Perception
Cognition
Insight
Appearance component of MSE.
General description of the patient’s general look and appearance.
- description of clothes
- well kempt / personal hygiene
- distinctive features (e.g. tattoos, adornments)
- mannerisms
Behaviour component of MSE.
Description of the patient’s ability to engage with you:
- general manner (e.g. threatening, tearful, agitated)
- eye contact
- rapport
Speech component of MSE.
Description of tone, rate and volume.
Normal speech can be described as: “spontaneous, logical, relevant and coherent.”
Characteristics of speech in
a) mania
b) depression
a) pressure of speech - increased rate and volume.
b) tone, rate and volume usually decreased.
Define circumstantial speech.
The patient cannot answer a question without giving excess unnecessary detail. However, they are able to answer the question in the end.
Define tangential speech.
The patient goes off on a tangent and will not answer the question.
Define perseveration speech.
Repeating ideas or words despite an attempt to change the topic.
Define clanging speech.
Speech pattern where sounds rather than meaning govern the use of words.
Define neologisms speech.
The use of made-up words.
For example, saying ‘head-shoe’ for ‘hat’ (seen in schizophrenia).
Define echolalia speech.
Repetition of someone else’s speech, including the question that was asked.
Mood component of MSE.
Description of the patients underlying emotion:
Subjective mood - how the patient describes their own mood.
Objective mood - your own interpretation of the patient’s mood.
(low) - (normal) - (elated)
Affect component of MSE.
Observed, short-term external demonstration of emotion.
Define
a) reactive affect
b) blunted affect
c) labile affect
d) suspicious affect
e) incongruous affect
a) shows appropriate emotional responses to external stimuli and matters.
b) lacking emotional response.
c) excessively changeable responses.
d) suspicious
e) out of tune with subject matter (e.g. laughing about bereavement).
Thought form component of MSE.
Refers to how the patient structures their thoughts, and whether they are connected to each other.
Summarise whether the patients thought were logical, relevant and coherent. Then explain any abnormalities in thought form.
Define thought disorders:
a) flight of ideas
b) loosening of associations
c) thought block
a) abnormal thoughts where patients leap from one topic to another, without links between them.
b) no discernible link between words or statements.
c) patient’s subjective experience of thought is abnormal (e.g. my mind goes blank).
Thought content component of MSE.
The actual content of the patient’s thoughts and whether they are suicidal:
- overvalued ideas
- ideas of reference
- delusions
- negative cognitions
- depersonalisation
- derealisation
- suicidal ideation
Define
a) ideas of reference
b) depersonalisation
c) derealisation
d) overvalued ideas
a) beliefs that other people are talking about them, but not with delusional intensity.
b) feeling as if they are not real (ie. they are watching themselves through glass).
c) feeling as if the world is not real (ie. the world is made out of cardboard).
d) understandable thoughts, that are pursued beyond bounds of reason to the point is causes distress (e.g. intense belief they are responsible for a death).
Perception component of MSE.
Describes whether the patient experiences phenomena which are not present:
- illusions
- hallucinations
- pseudohallucinations
Cognition component of MSE.
Involves testing the 5 basic aspects of brain function to see if the patient has functional impairment:
- consciousness
- orientation
- attention and concentration
- memory
- executive functioning
Insight component of MSE.
Describes the patient’s understanding of their condition, and its cause.
Does the patient realise they are ill?
Do they think they need treatment?
Which setting should they be in in their opinion?
