Shalinder Bhatia ST4

Shalinder Bhatia

ST4

Areas to cover

� Aggressive/disturbed behaviour

� Psychosis

� Alcohol and substance dependence

� Anxiety/panic disorder

� Suicidal ideation/Risk assessment

� Mental health legislation/MCA

� Physical symptoms in absence of organic disease

Case� Lucy - 29 year old woman found screaming at

Starbucks then threw coffee at the barista. Ran out of the coffee shop making some bizarre comments.

� Police were called by a member of public and she eventually found in the park, mumbling to herself.

What must the police do?

Section 136• Detaining mentally disordered person in public

place

• Police can take to place of safety and detain up to 24 hours to allow assessment of mental health

• Where is ‘Place of safety’ ?

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Lucy is brought to A&E on s136

• Continues to present as agitated and aggressive. • She is not allowing you to examine her• Shouting “I need to be taken to jail. I think I

contaminated someone with a virus and I need to go to jail. Don’t get near me…I will make you sick too.”

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Causes of agitated behaviour

Causes� Physical

o Acute infection (UTI, chest)

o Hypoglycaemia

o Hypoxia

o Head injury

o Post-ictal

Causes� Drug and Substance Misuse

o Acute alcohol/illicit substance intoxication or withdrawal

o Steroid psychosis

o Amphetamine psychosis

Causes� Acute mental health problems

o Acute schizophrenia or psychotic depression

o Manic episodes of bipolar disorder

o Personality disorder

o Severe anxiety disorder, panic disorder

Recognising agitated patient

Predictors of aggressive behaviour� Verbal outbursts

� Pacing, posturing

� Eye contact

� Invading personal space

� Body language – clenched fists etc

� Review any previous relevant history of violence

Investigations� Blood tests

� Urine drug screen – Legal highs ?

� Imaging if appropriate

Other information gathered� Blood work revealed mildly elevated WBC at 11.2,

otherwise all results including LFTs, and other markers unremarkable.

� Urine dipstick/toxicology is negative

� BP: 135/78, HR 82 and regular, physical exam unremarkable

� Pt is fully oriented and has not exhibited a waxing/waning level of consciousness

� Given the information you have what diagnoses are on your differential?

Differential diagnosis� Schizophrenia� Transient psychosis� Delusional disorder� Bipolar disorder� Depression� Substance misuse – drug induced� Dementia� Parkinson’s disease� PTSD� Personality disorders

Psychotic disorders due to a

General Medical Conditions

� Brain tumors

� Epilepsy

� Head injury

� Delirium

� Multiple Sclerosis

� Cushing’s syndrome

� Vitamin deficiencies

� Electrolyte abnormalities

� Thyroid disorders

� Uremia

� SLE

� HIV

� Anabolic steroids

� Corticosteroids

� Antimalarial drugs

� NMDA Encephalitis

Psychotic illnesses

Terminology� Psychosis

� disorder of thinking and perception where typically patients do not ascribe their symptoms to a mental disorder

� Positive symptoms� Delusions, hallucinations, thought disorder

� Negative symptoms� A deficit state

� Delusion� False unshakeable belief out of keeping with the

patients cultural educational and social background

TerminologyHallucination

A sensory perception experienced in the absence of a real stimulus

Prodrome

A definable period before the onset of psychotic symptoms during which functioning becomes impaired.

Diagnosis

� Diagnosis based on clinical findings

� No confirmatory tests

� Investigations might be required to rule out organic psychosis.

� Most information gained on first assessment

� Antipsychotic treatment can reduce strength of delusion/intensity of abnormal perceptions

History

� Important to gain patients trust by

� Recording presenting complaints first

� Listening empathically

� Open questions

� How have things been for you lately

� Do you think something funny has been going on

� Have you heard unusual noises or voices

� Could someone be behind this

History

� Enquire about 3 core mood symptoms

� Mood

� Energy

� Interest and pleasure

� Psychosis + major alterations in mood may indicate bipolar or schizoaffective disorders.

Other aspects of history� Symptoms in other systems especially neurological

and endocrine

� Past psychiatric symptoms

� Past medical history and medication

� Family history of mental health and suicide

� Alcohol and substance misuse

� Allergies and adverse drug reactions

Mental state examination� Thorough documentation

� General behaviour

� over arousal and hostility suggestive of positive symptoms.

� Irritability suggestive of elevated mood

� Catatonia and negativism rare

� Altered consciousness unusual in non organic psychosis

� Intermittent clouding suggests delirium

Mental state examination� General behaviour

� Disorganised speech indicates thought disorder

� Stilted and difficult conversation occurs with negative symptoms

� New words – neologisms

� Random changes in conversation

� Fast or pressured speech suggests mania

Mental State Examination� Mood

� Depressed or elevated

� Affect� Normal or flat

� Thoughts

� Abnormal perceptions

� Asses suicidal risk

� Cognitive impairment� Grossly abnormal indicates learning disability or organic

disorder

Collateral history� Important as family or friends may have noted strange

behaviour

� May identify a prodrome

� Acute stress causing symptoms

� Gain information about premorbid personality

� Are beliefs culturally sanctioned and not delusional

Positive psychotic symptoms� Paranoid delusion

� Any delusion that refers back to self

� Delusions of thought interference� Delusions that others can hear read, insert or steal one’s

thoughts

� Passivity phenomena� Beliefs that others can control your will, limb

movements, bodily functions or feelings.

� Thought echo� Hearing own thoughts spoken out loud

Positive psychotic symptoms� Third person auditory hallucinations

� Voices speaking about the patient, running commentaries – common in non-affective psychosis

� Hallucinations without affective content

� Second person auditory hallucinations

� Voices speaking to patient - may give commands

� Thought disorder

� Thought block, over inclusive thinking, difficulties in abstract thought – can’t explain proverbs

Negative symptoms� Apathy – disinterest blunted affect

� Emotional withdrawal – flat affect

� Odd or incongruous affect

� Smiling when recounting sad events

� Lack of attention to personal hygiene

� Poor rapport

� Reduced verbal and non verbal communication no eye contact

� Lack of spontaneity and flow of conversation

Back to Lucy� Remains agitated, aggressive

� On what legal grounds would you treat or restrain her ?

� ? 136

� ? MCA

� ? MHA

Management of Agitated

behaviour� MDT approach – Nursing team, HCA, medics etc

� Ensure have sufficient support – security/police.

� Fully assess the patient including mental state, collateral history if possible.

Management of Agitated

behaviour� Non pharmacological methods – De-escalation

methods

� Pharmacological – Consider oral medication first and discuss with the patient

� IM options –

� Lorazepam – Side effects

� Haloperidol or combine with Lorazepam

� Promethazine

� Aripiprazole

Post Rapid Tranquilisation� Check alertness, temperature, pulse, respiration and

blood pressure and oxygen saturations regularly and ensure it is recorded.

� If the patient is asleep or unconscious, it is important to continue monitoring..

Back to Lucy• The police officers are concerned about a cut on her

arm • You are the CT2 assigned to clerk her• She appears medically stable, but will need a surgical

review. • The surgical SpR is called but Lucy thinks she

“recognizes” her and declines any further treatment saying ‘I’d rather lose my arm then’.

Can the surgeons treat her anyway

under S136?

No!

• The MHA details the assessment and/or treatment of mental disorders and does not cover the treatment of ANY physical condition

• S136 is purely to be taken to place of safety for assessment

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The surgeon says…

• 'The patient just told me to P*** off. She did not express anything bizarre but was adamant did not want surgery. She looks like she need a surgical repair on her tendon damage though. Call me if she changes her mind.'

• The surgeon leaves

Lucy seems to be your

responsibility again

What do you do?

Call the surgeon back and suggest she should assess her capacity!

• Assessment of capacity undertaken by treating clinician (but psychiatrist may offer advice/assistance)!

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Capacity Assessment

• The surgical SpR comes back and requests you join the capacity assessment with her since Lucy seems to trust you

• You cast your mind back and remember the 5 Principles of Capacity

Principles of Capacity

1. A person has capacity unless proven otherwise

2. All possible steps to help a person make the decision must be taken (eg interpreters/time etc)

3. People are allowed to make unwise decisions

4. If a person lacks capacity the subsequent decision made by others for him/her must be in their best interests

5. When making a best interest decision on behalf of someone who lacks capacity the least restrictive option must be considered

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Assessing capacityThe 4 Step Test

�A patient is deemed to be competent if he/she can:

1. Understand the information relevant to the decision

2. Retain that information long enough to make the decision

3. Be able to weigh up that information

4.Communicate his/her decision (by any means e.g. blinking)

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• Lucy appears slightly more settled and isdeclining treatment, she continues to stateshe will infect others and at times appearsdistressed.

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Lucy becomes increasingly agitated and tries to leave

• Security staff prevent her leaving but she accuses them of being ‘in on it’

• She grabs a pen and stabs herself in the abdomen

• You take her back to bed and fast bleep the surgeons

• The Consultant arrives with the SpR who tells him the patient refused treatment.

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Is there anything else they should

do?

Re-assess Capacity

• Is decision and time specific

• The higher the stakes the more important it is to scrutinise all options available

• Lucy has sustained a more serious injury so the situation has changed and her capacity should be reassessed

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Lucy survives theatre and spends four days intubated in ITU before going to a surgical ward

• You are the surgical F2 on nights

• You are bleeped about Lucy, she is acting strangely and trying to leave

• Does the section 136 issued by the police still count?

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� No - expired 24 hours after arrival in A&E

� You're busy with another patient and can't leave

� What do you tell her to do?

Section 5(4)Nurses holding power

• Must be a Mental Health or Learning Disabilities Nurse

• Can hold up to 6 hours

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• You attend the ward ASAP. Lucy is being kept on the ward by hospital security as instructed by the nurse in charge (MCA-best interest)

• She is agitated and threatening the security guards. She is arguing with someone you can't see and not engaging with you.

• Shouting that she needs to be let out otherwise she will infect others and harm them.

• What do you do?

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Section 5(2)

• Allows consultant(or nominated deputy) to prevent patient leaving for up to 72 hours to allow MHA Assessment

• Patient must be in-patient (not A&E or OP clinic) suffering from a MH problem of nature/degree that warrants formal admission to hospital

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• While on S5(2) Lucy is responding to unseen stimuli, is paranoid about nursing staff and refuses all treatment

• Can you use S5(2) to force medication to help with her psychotic symptoms?

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No! � S5(2) does not give authority to treat

(could use MCA- Best Interest Decision if lacks capacity)

Lucy is medically fit for discharge she's not yet had a MHA assessment there are 48 hours left on her S5(2)

• Who do you call to ensure the MHA assessment happens?

• Psych Liaison (or DSH) will point you in the right direction or contact the on-call social worker

• MHA will be arranged involving an AMHP and 2 doctors

• Lucy is assessed and the S5(2) converted to S2

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MHA Assessment

• A doctor, mental health professional or the patient's nearest relative can request a MHA

• It must happen if someone is on S5(2), 5(4), 136 or 135 (unless lapsed)

• An AMHP (specially trained social worker) co-ordinates

Pt detained on S2

• Compulsory admission for assessment

• 'Nature or degree of illness is such they warrant detention in hospital....in the interests of her own health or safety or with a view to the protection of other persons'

• Up to 28 days

• Can have treatment as part of assessment

• Right of appeal within first 14 days

MHA/MCA�A 45 year old woman with Personality

Disorder attends A&E for the 45th time this year saying she's taken a staggered OD. She then decides to leave.

�A severely depressed lady is admitted with dehydration. She is refusing fluids as she wants to die.

�Patient with anorexia – treating with NG feed ?

Thank You!