Lecture - Forensic Psychiatry Flashcards
CASE:
Luke (20yo) is alleged to have stabbed a stranger in the street, who later died in hospital. Luke was reported to be acting bizarrely by the arresting officers, muttering under his breath and looked perplexed. You are called to undertake a MHAA on him in the local police station. No past psychiatric history, does not appear intoxicated and physically well.
During your assessment, he presents as guarded and reluctant to engage. No other abnormal behaviour noted. You cannot exclude psychotic illness. He is reasonably calm.
3
NB: you need to be on a section 3 to then be converted to a CTO.
Luke ends up in the prison healthcare wing.
Over one week, a senior MH nurse observes him responding to hallucinations, displaying bizarre behaviour and with rambling, chaotic speech.
When you review him, he is fearful. Accuses you of being a Freemason. Describes a plot against him involving the Freemasons and the American government. Derailment in his thinking. Describes 3rd person and command auditory hallucinations. Believes that you are causing him pain in his thigh muscles with your mind. Mood is objectively euthymic.
What is the most likely diagnosis?
- a)Schizoaffective Disorder
- b)Severe Depression with Psychosis
- c)First episode psychosis
- d)Adjustment Disorder
c
“Mood is euthymic” so schizoaffective and mood disorders can be ruled out.
The senior MH nurse informs you Luke is being closely observed. He has not demonstrated any violent or suicidal behaviour. You decide that he should be started on a medication to help control his symptoms.
Which would be the most appropriate first line treatment?
- a)Haloperidol depot injection
- b)Olanzapine orally
- c)Clonazepam
- d)Clozapine
b
Luke’s mental state continues to deteriorate on the prison healthcare wing. He attempts to hang himself in his cell and becomes more aggressive with prison healthcare staff. He says suicide is the only way to spare him the torture by the Freemasons. He is agitated and clearly distressed by auditory hallucinations. Refusing oral olanzapine consistently. He is still awaiting his trial. You decide that he requires transfer to a MSU to manage his risks and treat his psychosis.
What section of the Mental Health Act should you use?
- a)Section 136
- b)Section 2
- c)Section 5(2)
- d)Section 48
d
Due to the serious nature of the alleged offence, a Restriction Order is applied alongside the Section 48. In this case it is a Section 49.
Who has the authority to apply the Restriction Order?
- a)The Ministry of Justice
- b)A Section 12 Approved Doctor
- c)The Crown Court
- d)The Prison Governor
a - 48/49 appllied due to serious nature of offence
Usually seeing two number with a / in between means there is an additional restriction order.
Luke is transferred to MSU under Section 48/49 for treatment of his psychosis. Despite persistent attempts to engage him, he continues to refuse all oral medication. Presents as high risk of violence and suicide/self-harm. Managed in the Extra Care Area (ECA) and sometimes requires time in the seclusion room for his own safety and the safety of staff and other patients. He is given frequent IM benzodiazepines and antipsychotic medication as PRN.
What would be the most appropriate medical management?
- a)Continue with PRN regime until sufficiently settled to accept oral medication
- b)Prescribe olanzapine in an orodispersible form
- c)Stop PRN regime and manage in seclusion until sufficiently settled to accept oral medication
- d)Prescribe a longer acting intramuscular antipsychotic medication
d - safer to consider this as he is so unwell and every time the staff enter they are putting themselves at risk.
What are the risk factors fro violence in inpatient settings with respect to the patient?
- Being young
- History of violence
- Being compulsorily admitted
- Co-morbid substance misuse
- Being in the acute phase of the illness
What are the risk factors for violence in an inpatient unit with respect to the environment?
- Lack of structured activity
- High use of temporary staff
- Low levels of staff-patient interaction
- Poor staffing levels
- Poorly defined staffing roles
- Unpredictable ward programmes
- Lack of privacy
- Overcrowding
- Poor physical facilities
- Availability of weapons
Define rapid tranquilisation.
Use of medication by the parenteral route (usually IM) if oral medication is not possible or appropriate and urgent sedation with medication is needed.
What are the considerations for rapid tranquilisation?
Oral medication is always preferred option if possible, otherwise…
IM lorazepam +/- IM haloperidol – other options include promethazine, aripiprazole, olanzapine
Be aware:
- Total dose of daily medication prescribed/administered
- PMHx, pregnancy
- Cardiac problems, prolonged QTc
Monitor: BP/HR/RR every 5 minutes, temperature every 30 minutes and look for evidence of dystonia
Documentation
Debrief
Define seclusion.
Defined as: “the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.”
Is seclusion always locked? How often are obs done? What is the aim?
Can be:
- Short-term or long term segregation
- Locked or unlocked
- Patient is 1:1 when in seclusion room with 15 min obs
- Regular reviews – by nurses and medics
- Aim shortest time possible.
After several months on MSU, Luke makes a full recovery from his psychotic episode. He prefers to continue with depot medication. His past convictions suggest a significant history of violent offences. You have been able to obtain a very good collateral history from members of his family.
Which would be the most appropriate rating scale to use to assess his risk level to others?
- a)PCL-R
- b)HCR-20
- c)MMSE
- d)HoNOS
A: HCR-20 - historical, clinical, risk and management tool, contains 20 items
HoNOS - overall grading for many disorders, PLC-R is used for psychopathy assessment
What scale is used for assessment of psychopathy?
PCL-R
What are the differences between ODD and conduct disorder?
