Dr N Gupta (SpR)

Dr T George (SpR)
20.03.2019
 General Overview of Mental Health Services
 Psychiatric assessment (History taking, Mental State
Examination and Risk Assessment)
 Management of common psychiatric diagnosis

 Psychiatric emergencies

Suicide attempt/self harm/overdose

Psychotropic medication related emergencies
Delirium
Severe behavioural disturbance
 Mental health Act ; section 5(2)
• Primary Care
• Crisis Team/HTT
• A&E and Liaison
• Secondary MHS
 OPC
 Inpatients
 CMHT
 CAMHS
 Old Age service
 Eating Disorder Service
 Early Intervention Team
 Drug and alcohol Service
 Perinatal Psychiatry
Obtain information from sources available on:

 Name, dob, address and demographics

(marital status and employment)
 Source of referral
 Legal status
 Previous history documented
 Open questions egs..
 Onset, duration, triggers
 Impact on ability to function
 Response to any treatment that has been
initiated
 You will be considering…
◦ Depression
◦ Anxiety
◦ Psychosis
◦ Bipolar
◦ Personality disorder
◦ Organic causes – physical illness, dementia, substance
misuse
 Diagnosis (may change and evolve over time)

 Treatment (inc psychological) – how

successful?

 Admission to hospital – if so were they

sectioned?

 Suicide attempts/DSH
 Medical co-morbidities

 To rule out organic causes

◦ Depression
◦ Anxiety
◦ Psychosis

Current medications
Any allergies
 Pregnancy and delivery

 Any problems in neonatal period?

 Development and milestones

 What were they like as a child?

 Did they make friends easily

 How did they find school?

 How was family life

 Any abuse – was there anything in your childhood that you

remember was particularly difficult or upsetting for you?
 Family tree
 Mental illness in family
 Suicide in family
 Housing
 Employment
 Hobbies
 Relationships
 Any contact with the police
 Cautions, charges, convictions
 Involvement of forensic mental health
services
 What are they using currently
 When did they start
 why did they start
 Did use of substances pre-date mental health
problems or was it used to cope with existing
problems
 How much are they using?
 Are there features of dependence?
 How does use of alcohol/drugs affect their
mental state?
Mental State
Examination
 Appearance and Behavior
 Mood
 Speech
 Thought – Form, Content
 Perception
 Cognition
 Insight
 RISK
Examples:
 Tall slim man of African-Caribbean descent
 …is a – year old white British man of average
height and built
 He was casually dressed; dressed appropriate
to the climate
 Normal grooming and hygiene
 He was well hydrated and nourished; no signs
of self neglect
Examples:
 Warm in demeanour; He was pleasant and
polite in manner
 Good eye contact rapport was established.
 He was able to give a good account of his
current situation.
 He appeared tensed , teary, withdrawn,
anxious, guarded, evasive and irritable but
was cooperative throughout interview..
 There was no psychomotorical agitation and
retardation noticed.
 Objectively he appeared low, Elated,
dysthymic /apathic (showing or feeling no
interest, enthusiasm, or concern) with
reactive affect.

 Affect was appropriate with

normal/restricted range and reactivity and
mood congruent or was flat/blunted
(reduced intensity)/labile
Tone: Monotone

Rate: Rapid- pressured, reduced

Volume: loud, soft

Quantity: spontaneous answers/articulated

herself clearly; there was poverty of speech;
monosyllabic/irrelevant answers, talkative
Normally every thought we have has 4 properties:

1. CONTENT - What is being thought about?

E.g. Delusions of persecution, suicidal thoughts, obsessions,
hypochondrial etc.

2. FORM- In what manner is the thought present?

E.g. Loosened associations(no link between thoughts), tangentiality,
circumstantiality , rhyming etc.

3. STREAM/FLOW- How is it being thought about? Slow, fast.

E.g. Poverty of thought, pressure of speech, flight of ideas(link between
ideas)

4. CONTROL of thoughts-Where is it from?

E.g obsessions (unwanted, intrusive, own thoughts), thought alienation –
insertion/withdrawal (under external control)
Thought content could be deciphered from ones behavior, but thought form and stream cannot be
studied without being expressed as speech.
 What has been lately on your mind?
 Do you have any particular worries?
 Do you feel people are watching you?
 When you watch TV do you ever feel that
the stories refer directly to you?
 Do you ever feel that people are trying to
harm you?
 Do you worry that you have serious illness?
Abnormal perceptual experiences may be divided in 2 types:

1. Altered perception:
Illusions –distorted internal perception of a real external
stimulus(Affect, Completion e.g. CCOK-COOK, Pareidolic-
e.g.seeing faces in clouds

Sensory distortion –changes are in the perceived intensity or quality

of a real external stimulus e.g. in organic conditions or drug
ingestion (Hyperacusis, Micropsia, more bright colors in Mania)

2. False perceptions:
True Hallucinations- is exactly like a true sensory perception BUT
without an actual object, in outer objective space e.g.
Auditory,Visual,Hypnagogic/pompic,etc.

Pseudo-hallucinations –is exactly like a true sensory perception BUT

it happens in inner subjective space e.g. hearing voices inside
my head
 Now I want to ask you about some
experiences which sometime people have
but find difficult to talk about. These are
questions I ask everyone.
 Have you ever had the experience of
hearing noises or voices when there was
no-one around to explain it?
 Have you every seen any visions no one
else could see?
• Consciousness - Alert/Drowsy/Fluctuating
• Orientation - Time/Place/Person
• Concentration + Attention
e.g. serial seven test, spelling world
backwards
• Memory
->short-term memory e.g. digit span,
recalling a set of words
->long-term memory: Recent e.g. last
meal
Remote e.g. historical facts
Examples:
 He was alert and oriented to time, place
and person.
 Regarding his concentration, he was able
to sustain the focus to all my question.
 His higher cognitive functions appeared to
be grossly intact.
• Can be defined as “the correct attitude to morbid
change in oneself”.

• It’s a simple concept that includes a number of

beliefs about the nature of the symptoms, their
causation and the most appropriate way of dealing
with them.

• Impairment of insight can give a rough measure of

severity of psychotic symptoms

• Regaining insight into the pathological nature of

psychotic beliefs can give a similar rough measure
of the improvement with treatment.
 Do you belief that these experiences are
part of an illness?
 If so - What illness do you have? Medical or
Psychiatric?
 How do you plan to get help for this
problem?
 Are you willing to accept the treatment
advised by the doctor?
 To self (suicide, self-harm):
Low/medium/high
 To others:
 Self-neglect:
 From others (exploitation, vulnerability):
 Working diagnosis and considering differentials
 Management Plan

Inpatients’
 PE , routine blood tests, Urine analysis, ECG.
 PRN medications and regular medications
 Handover to the team(on call)
 Instructions to nurses regarding Obs level

Out-patients’
 Medication
 Psychology – Treatment Team
 Review OPA
 CR/HTT, CPN, Inpatient, MHA
 Give information to patient/leaflets
 Anti-depressants
 Anti-psychotics
 Mood stabilisers
 Benzodiazepines
 Hypnotics
 GI upsets
 sedation
 Weight gain
 Hyperprolactinemia
 Sexual side effects
 Extra-pyramidal side effects; rigidity, tremors,
bradykinesia
 Akathisia
 tardive dyskinesia
 Acute dystonia
 Cardiac side effects; QT prolongation
 CBT
 Interpersonal therapy
 Psychodynamic therapy
 DBT
 EMDR
 Group therapies
 Child safeguarding
 Education and support for carer’s
 Financial support
 Employment
 Driving
 Psychiatric
Emergencies
 A – Antecedent
 B - Behaviour
 C – Consequence
 Mood/Mental state BEFORE the suicide
attempt e.g. feeling low.

 Was the attempt planned or impulsive?

 If the attempt was planned:

- Any precautions planned not to be found?
- Written notes to friends/family
- Closing bank accounts
 Any disinhibition factors e.g. alcohol, drugs.

 How dangerous was the attempt (degree and

nature of violence)?

 Did the person believe that 8 paracetamol can

kill him?

 Precautions against to be found.

 Final acts e.g. closing bank accounts, notes
etc.
 Current feelings after suicide attempt e.g.
remorse?

 Has anything changed?

 Thoughts of further suicide?

 Protective factors?
 Therapeutic Index
 Side effects
 Toxic effects
 Management
 Rare but fatal syndrome due to anti-
depressants
 Altered mental state, agitation, rigidity,
tremor, diarrhoea, ataxia and hyperthermia,
autonomic symptoms
 Management
 Transfer to medical ward
 Stop anti-psychotic; BDZ; IV sodium bicarbonate;
dantrolene
 Supportive treatment;
 Rare life threatening idiosyncratic reaction to
high dose increase of anti-psychotics
 Physical and neurological side effects
 Fever, muscular rigidity, altered mental state
and autonomic dysfunction; high mortality
 Management
 Transfer to medical ward
 Stop anti-psychotic; BDZ; IV sodium
bicarbonate; dantrolene
 Supportive treatment;
 Agranulocytosis/ neutropenia
 Myocarditis
 Clozapine Monitoring
 Acute confusional state
 Causes
 Symptoms
 Management;
Assessment
Environmental measures
MMSE
Avoid sedation unless necessary
 Acute change in person’s normal behaviour
 Manifested as agitation, anger, shouting,
screaming, threatening to harm self or
others
 Causes:
 General approach: full assessment
 Management; Physical/psychiatric/police
 Psychiatric; MHA, Tranquilisation,
observation level
 We have MH legislation for 3 reasons:
 Mental Disorder can impair ability to make decisions about
treatment
 Provision of safeguards and protection for vulnerable adults
 Prevention of harm to self and others

 MHA 1983 sets out relevant procedures for E&W.

 Criterion for detention
 Section 2, 3, and section 5 (2)
 Section 5(2): emergency detention of patients on wards; done
by duty SHO, duration is 72 hours and another assessment to
decide if patient needs to be detained on 2/3 or informal