Transcript Week 4 – Assessment of Acute Psychosis

Assessment of Acute
Psychosis
Learning Objectives
• To understand the meaning of key terms
• To appreciate range of signs and symptoms
encountered in psychotic patients
• To appreciate the importance of a
comprehensive multidisciplinary approach in
acute psychosis
• To be aware of challenges, difficulties and
dangers inherent in the assessment process.
Core curriculum
• A competency based curriculum for specialist core training in
Psychiatry
• February 2009
Intended learning outcomes
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1 history and examination
2 differential diagnosis and formulation
3 clinical management plan
4 risk assessment
5 therapeutic interviews
6 record keeping
7 management of severe and enduring illness
8 communication
9 team working
• 10 – 18
Intended learning outcome 1
• Knowledge
• Define signs and symptoms found in patients presenting with psychiatric and
common medical disorders
• Recognise the importance of historical data from multiple sources
• Skills
• Elicit a complete clinical history, including psychiatric history, that identifies the
main or chief complaint, the history of the present illness, the past psychiatric
history, medications, general medical history, review of systems, substance
abuse history, forensic history, family history, personal, social and developmental
history
• Overcome difficulties of language, physical and sensory impairment
• Gather this factual information whilst understanding the meaning these facts
hold for the patient and eliciting the patient’s narrative of their life experience
• Attitudes demonstrated through behaviours
• Show empathy with patients. Appreciate the interaction and importance of
psychological, social and spiritual factors in patients and their support
Core Curriculum
• Demonstrate interviewing skills: The appropriate initiation of the
interview, the establishment of rapport, the appropriate use of open
ended and closed questions, techniques for asking difficult
questions, the appropriate use of facilitation, empathy, clarification,
confrontation, reassurance, silence and summary statements. Solicit
and acknowledge expression of the patients’ ideas, concerns,
questions and feelings.
• Understand the ways in which patients may communicate that are
not directly verbal and have symbolic or unconscious elements.
• Communicate information to patients in a clear fashion
• Appropriately close interviews
Generic Assessment in Psychiatry
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History
Mental State Examination
Risk assessment
Investigations
Management to facilitate assessment
Psychosis (and neurosis)
• ‘Psychoses are major mental illnesses. They are exceedingly
difficult to define although they are usually said to be
characterised by severe symptoms, such as delusions and
hallucinations, and by lack of insight’ Gelder 1983
• Neurosis is a psychological reaction to acute of continuous
perceived stress, expressed in emotion or behaviour
ultimately inappropriate in dealing with that stress’ Sims 1983
Psychosis
A mental illness which markedly interferes with a person’s
capacity to meet everyday demands.
Any mental disorder which involves loss of contacts with
reality and deterioration of social functioning.
A mental disorder in which a serious inability to think, perceive
and judge clearly affect ability to function normally.
Hierarchy of psychiatric
classification
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Organic syndromes
Functional psychoses
Neuroses
Adjustment reactions
• Pyramid or hierarchy?
ICD Classification
F00 Dementia
F10 Disorders due to psychoactive
substance use
F20 Schizophrenia, schizotypal and delusional disorders
F30 Affective disorders
Organic
Schizophreniform
Psychosis
Differential
Affective
Other
Malingering
Not psychosis
Personality disorder
Neurosis
Neurodevelopmental disorder
Setting the Scene for Assessment
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Background information +++ (RIO and other sources)
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Get help
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Create a safe environment
Taking Care
Predictors for Immediate Violence/Aggression
• Previous history of violence
• Young male patient
• Forensic history
• Substance misuse
• Antisocial explosive impulsive traits
• Associated with subculture prone to violence
• Social restlessness, rootlessness
• Specific threats to named victims
History
• Full history and mental state examination (other
informants, interpreter)
• Presenting complaints
Symptom cluster and pattern – and a sense of order in
which symptoms emerge if you can
Onset and duration
Precipitants
Exacerbating factors
Interventions and effect
History
• Any psychiatric history
• Eg previous depressive episodes whether or not sought
treatment relevant in presentation of mania with psychosis
• Previous BLIPS or subthreshold psychotic symptoms
• DSH
• Drug history; prescribed, illicit, alcohol
• Family history - ask questions if positive history
History
• Personal History
• Early life. Neurodevelopmental history
• Best level of education and employment – and
change since
• Current circumstances (including housing and
financial issues)
• Current/previous interface with criminal justice
system
• Social support
Key Symptoms and Signs
• Level of consciousness
• Level of orientation
• Motor symptoms
• Disordered form of thought
• Perceptual symptoms
• Disordered content of thought
• Passivity phenomena
• Disordered mood
• Insight
APEARANCE AND
BEHAVIOUR:
OBSERVATION
Mental State Examination
• Appearance
• Behaviour (including abnormal movements)
• Speech
Form
Content
Mental State Examination
• Mood
• Thought
Form (assessed in speech)
Content (delusions, obsessions,
overvalued ideas)
Possession (who’s thoughts are they?)
Remember suicidal ideation
homicidal ideation
Mental State Examination
• Perception
Hallucinations
Illusions
All modalities
• Insight (and capacity)
• Bedside cognitive function tests
Physical Examination
• All patients presenting with an acute psychosis require a full
physical examination
• Including neurological examination
Differential Diagnosis
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specific psychotic symptoms
severity
duration
presence of other symptoms or signs – affective, organic
Presence of FRS
• working diagnosis or diagnoses
• Formulation
• vulnerability factors, triggers
‘why has this particular patient developed this particular
illness at this particular time’
Investigations
Standard
Physical examination
FBC, U+E, LFT, TFT, Fasting Glucose
Urine drug screen
ECG
Also consider
Imaging
CT/MRI
EEG
CK
If suspect encephalitis
liaise with neurology
anti –nmda antibodies
MRI, EEG, CSF
Potential Dangers: Acute Brain
Syndrome
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Patient over 40 with no past psychiatric history
Abnormal vital signs
Clouding of consciousness
Disorientation
Visual hallucinations
Medical Causes of Disturbed
Behaviour
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Intoxication
Overdose
Delirium tremens
Head injury
Prescribed medication
Meningitis/encephalitis
Vasculitis
Hypoglycaemia
Impaired cerebral oxygenation
Wernicke’s encephalopathy
TLE
Paraneoplastic syndrome
Dementia
QUESTIONS: IN PAIRS
• HOW DO WE BEGIN?
• ESTABLISHING RAPPORT WITH THE ACUTELY
PSYCHOTIC PATIENT
• PHRASING DIFFICULT QUESTIONS
• ASKING ABOUT FIRST RANK SYMPTOMS
QUESTIONS
• You are there to help: ESTABLISH THERAPEUTIC ALLIANCE
• Honesty without confrontation
Examples
• “It sounds as though you have been though a lot recently”
• “If I understand a bit more about what you have been
through, we might be able to help”
Asking about First Rank Symptoms
• Voices:
• Passivity:
• Thought interference:
• NORMALIZATION and EMPATHY
Examples
• “Does your mind ever play tricks on you”
• “Do you hear voices when no-one is there?”
Examples
• “When we are under a lot of stress, it is common to have
usual or frightening experiences, such as hearing a noise”
• “Tell me a bit more about that… does it ever sound like a
voice?”
Suicide: Risk Assessment
• MENTAL STATE
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Hopelessness
Unexplained Improvement of Symptoms esp depression
Psychotic Symptoms
Development of insight
Suicide: Risk Assessment
• Always ask!
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How do you feel about the future? (i.e. do you have one?)
Do you feel hopeless?
Have things got so bad you felt as if you can’t carry on?
Have you ever had thoughts of harming yourself
Have you ever thought of ending your life?
Do you think you would act on these thoughts?
Potential Dangers of Violence and
Aggression
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Command hallucinations
Irritability, hostility, suspiciousness
Morbid jealousy/erotomania
Misidentification phenomena
Passivity and alienation
Violence: Risk Assessment
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Mental illness is a risk factor for violence
Small compared to total violence in society
Co-morbid substance misuse increases risk
Active symptoms are more important than underlying diagnosis
Violence : the facts
• 102 out of 718 homicide offenders (14%) had past contact with
mental health services
• 58(8%) had contact in the year prior to the offence
• Only 15 were receiving intensive community care
• 4% had schizophrenia
Violence: Risk Assessment
• HISTORY
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Gender (M>F)
<35y old
Past History of Violence
Itinerant lifestyle
Current substance misuse
Lack of education/ skills
Disposition (suspiciousness, impulsivity, irritability)
History of childhood abuse/ disorganisation
Lack of education/ skills
Violence: Risk Assessment
• MENTAL STATE:
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Fear, anger, frustration, humiliation, self-righteousness and jealousy
Command Hallucinations
Persecutory delusions, passivity phenomena
Clouding of consciousness/ intoxication/ confusion
TIPS:
• Get as much information as you can before the
interview.
• Collaboration not collusion
• Keep it short if necessary
• Know when to finish
Detaining patients
Has patient got insight?
Has patient got capacity?
Validity of consent to treatment/admission
Will consent be sustained over a sufficient
period?
MHA trumps MCA
Summary
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Keep safe, and manage risks
Take care and time
. history
. examination
. physical examination
. investigations
3. Get a collateral history
4. Perform joint assessments where possible, time limited
MCQS
The following are Schneiderian 1st Rank symptoms:
• Thought echo
• Ideas of reference
• Somatic hallucinations
• Delusional mood
• Flatness of affect
MCQS
The following are recognized associations with delusional jealousy:
• Depression
• Alcoholism
• Impotence
• Personality disorder
• Pervasive sense of inadequacy
MCQS
“Normal” experiences include:
• A. Jamais vu
• B. Delusional perception
• C. Derealization
• D. Visual hallucinations
• E. Deja-vecu