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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• 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
• 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
• Organic syndromes• Functional psychoses• Neuroses• Adjustment reactions
• Pyramid or hierarchy?
ICD Classification
F00 DementiaF10 Disorders due to psychoactive
substance useF20 Schizophrenia, schizotypal and delusional disordersF30 Affective disorders
Organic Schizophreniform Psychosis Affective Differential Other Malingering Not psychosis Personality disorder Neurosis
Neurodevelopmental disorder
Setting the Scene for Assessment
1 Background information +++ (RIO and other sources)
2 Get help
3 Create a safe environment
Taking CarePredictors 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• 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 considerImaging
CT/MRI EEG
CK
If suspect encephalitisliaise with neurologyanti –nmda antibodiesMRI, EEG, CSF
Potential Dangers: Acute Brain Syndrome
• Patient over 40 with no past psychiatric history• Abnormal vital signs• Clouding of consciousness• Disorientation• Visual hallucinations
Medical Causes of Disturbed Behaviour• 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 AssessmentSuicide: Risk Assessment
• MENTAL STATE• Hopelessness• Unexplained Improvement of Symptoms esp depression• Psychotic Symptoms• Development of insight
Suicide: Risk AssessmentSuicide: Risk Assessment
• Always ask!
• 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
• Command hallucinations• Irritability, hostility, suspiciousness • Morbid jealousy/erotomania• Misidentification phenomena• Passivity and alienation
Violence: Risk AssessmentViolence: Risk Assessment
• 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 factsViolence : 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 AssessmentViolence: Risk Assessment
• HISTORY• 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 AssessmentViolence: Risk Assessment
• MENTAL STATE:• 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 patientsHas 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
1. Keep safe, and manage risks2. Take care and time . history . examination . physical examination . investigations3. Get a collateral history4. Perform joint assessments where possible, time limited
MCQSThe following are Schneiderian 1st Rank symptoms: • Thought echo
• Ideas of reference
• Somatic hallucinations
• Delusional mood
• Flatness of affect
MCQSThe 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