intro

Question 1

How are psychiatric conditions categorised?

Answer 1

Organic and functional

then psychotic and non psychotic

Question 2

What are organic psychotic diseases?

Answer 2

delerium, epilepsy, other psychosis e.g. drugs

Question 3

what are organic non-psychotic diseases?

Answer 3

Anxiety due to hyperthyroidism

Question 4

What are functional psychotic diseases?

Answer 4

psychosis, depression, schizophrenia, mania

Question 5

what are functional non-psychotic diseases?

Answer 5

OCD, phobias, depression

Question 6

What is the order in which psychiatric diseases should be prioritised?

Answer 6

Organic disorders
Functional psychosis
Non-psychotic disorders
Personality disorders

Question 7

what is needed to detain a patient?

Answer 7

Suffering from mental disorder (but may not be formally diagnosed)
AND
At risk to own health AND/OR own safety AND/OR risk to others AND/OR risk of serious neglect/exploitation
AND
Unwilling to go to hospital voluntarily

Question 8

Which people are needed to section people?

Answer 8

• Assessed by 2 Drs (preferably one which already knows patient – GP) and 1 AMPH
o One doctor must be section 12 approved
• Each Dr must determine their own criteria for detention
• The AMPH is always responsible for making the application and can disagree with and overrule Drs
o Nearest relative can rarely act as AMPH
• Actual detainment is from hospital managers

Question 9

What is a section 2?

Answer 9

Admission for assessment
• Grounds: MH disorder
• For: assessment (some treatment can be given but only for mental disorder or direct results/causes)
• Max duration: 28days
• Appeal: w/i 14 days
• Applied by: AMPH +2 Drs (1 approved)
• CANNOT BE RENEWED – MUST CONVERT TO SECTION 3

Question 10

What is a section 3?

Answer 10

Admission for Rx
• Grounds: MH disorder
• For: Rx of the mental disorder/cause of mental disorder and consequences of mental disorder
• Max duration: 6months
• Appeal: Within the first 6 months then every time it’s renewed
• Can be renewed – two chunks of six months then after that renewed yearly)
• Applied by: AMPH + 2 Drs (must have seen pt w/i 24 hrs, 1 approved)
• Lots of travel/ insurance implications so reluctant to use this unless necessary.

Question 11

What is a section 5(2)?

Answer 11

Drs Holding Power
Grounds: detention of inpatient only (not A&E), MH disorder
• Demonstrate a mental disorder
• Identify associated risks (to self/others)
• State why continued informal admission is not possible (refusal to stay/lack capacity to make decision)
• State that therefore person needs formal assessment under MHS
• For: allows time for MHA assessment - sec 2/3 to be acted (no authority to treat during these 72 hours!! (physically or mentally))
• Max duration: 72hrs
• Cannot be appealed, only released by responsible clinician
• Applied by: consultant in charge of care, or nominated deputy, FY2 or above

Question 12

What is a section 5(4)?

Answer 12

nurses holding power

same as Dr but 6 hours

Question 13

What is a section 4?

Answer 13

• Grounds: urgent detainment for assessment of person in public, may then convert  sec 2. No authority to Rx
• Duration: 72hrs
• Applied by: AMPH + any registered Dr (FY2+)

Question 14

What is a section 7?

Answer 14

Guardianship
Guardian has powers to
• Require pt to live at specified place
• Require pt to attend specified place for training/medical assessment
• Allow health worker to see patient in own home
o Cannot force pt to receive Rx

Question 15

What is a section 17?

Answer 15

AUTHORISED LEAVE
• Responsible clinician allows detained patient to leave hospital for a certain period of time,
• Also includes CTO  to receive treatment in community. But they can recall you anytime and give you immediate treatment if necessary - e.g. they can be brought back in to have a depot every month if not compliant.
• Also have to live under certain conditions. While on CTO you have right to an IMHA (independent mental health advocate)

Question 16

What is a section 117?

Answer 16

• A patient under section 3 is automatically placed under Section 117 at the time of discharge from the Section 3. Under Section 117 it is the duty of the local health services to provide aftercare, with a care package aimed at rehabilitation and relapse prevention.
• The patient is under no obligation to accept this aftercare

Question 17

What is a section 135?

Answer 17

o Police warrant for search and removal of pt -if MH disorder and being neglected/unable to care for themselves  Removal from private area e.g. a patient’s home, to place of safety. Police get AMPH to apply to magistrate for this.

Question 18

What is a section 136?

Answer 18

o Police officer may detain patient in public place if they suspect MH disorder to take to safe place e.g. 136 suite
o 24 hours

Question 19

what is a section 37?

Answer 19

o Sent by courts to hospital (rather than prison)

Question 20

what is a section 41?

Answer 20

o Restriction disorder. Conditional discharge. E.g. you are released from hospital as long as you live at a certain address and comply with treatment

Question 21

what is a section 62?

Answer 21

o Allows treatment without consent. Need a SOAD (second opinion appointed doctor) to justify that the treatment is clinically indicated. Lasts for 28 days.

Question 22

what are the rules for reviewing treatment under section?

Answer 22

• you can treat a patient without capacity without consent for up to 3 months
• . If a patient lacks capacity after 3 months and still disagrees to treatment, the clinician must fill out a T3 form (Consent to Treat). It is good practice to repeat this after a year.
• If the patient has capacity after 3 months and agrees to treatment you fill out a T2 form. This specifies exactly what treatment is being given – you must only give this otherwise it’s assault.

Question 23

Who sits in on review tribunals?

Answer 23

• Legal member (usually a solicitor or a barrister),
• Doctor (usually a psychiatrist)
• Lay member (a person who is not medically or legally trained) with some mental health experience.
• You, the Responsible Clinician and social worker will also be at the tribunal obviously
• Patient can also choose to attend

Question 24

How do you decide someone lacks capacity?

Answer 24

• A person is always assumed to have capacity
• MCA is decision-specific & time-specific

2 stage process
1	Diagnostic test
a.	At the time of the decision the pt has an impairment of or disturbance in functioning of the mind or brain
2	Functional test, inability to
a.	Understand info relevant to decision
b.	Retain that info
c.	Use or weigh that info
d.	Communicate their decision

Question 25

What do you do if someone lacks capacity?

Answer 25

If no capacity, make decision in their BEST INTERESTS (consider waiting until they regain capacity, person’s past & present wishes, beliefs/values, views of anyone named by pt, POA)

Question 26

What are the rules around capacity in minors? (5)

Answer 26

As far as possible minors ought to be involved in decisions about their care, whether or not they are deemed competent. • Decisions on behalf of a minor can be made by a person with parental responsibility or by High Court • 16 and 17 year olds are deemed competent by the same standards as adults (Family Law Reform Act 1969). o However, they cannot refuse treatment if it has been agreed by a person of parental responsibility or the Court, and it is in their best interests • UNDER 16S MAY BE DEEMED COMPETENT to accept an intervention if they are mature enough to fully understand what is proposed (Gillick competency/Fraser guidelines) o Competency must be proved • Ideally, the consent of a person with parental responsibility should also be sought. However, the decision of a competent minor to accept treatment cannot be overruled by a parent • A court order may be obtained to overrule the decision of a competent minor or parent if it is considered in the best interests of the minor

Question 27

What are some considerations around psych issues in pregnancy?

Answer 27

* Previous postpartum depression (PPD) gives a 50% risk in next pregnancy * Previous postpartum depression + bipolar gives 75-100% risk in next pregnancy. * 1/7 chance of post-partum relapse if had treatment in secondary care for a psychiatric condition. * Use Edinburgh post-natal depression scale * PND can deteriorate into PNP or PNP can be a stand alone condition * Differentiate from ‘Baby blues’ which affect 80% new mothers in the first 2 weeks. Should settle by four weeks. If severe symptoms over 2-4 weeks, start thinking of PND. * Can also get ‘Baby pinks’ – hypomania or mania.

Question 28

Are SSRIs safe in pregnancy?

Answer 28

o First trimester probably not teratogenic. Can get postnatal adaptation syndrome (8-48hrs transient): Jittery, irritable, crying, poor feeding and poor temperature regulation. o Breastfeeding generally fine at full term. Sertraline 1% in breast milk. Fluoxitine 4-6%. As long as less than 10% should be safe.

Question 29

is venlafaxine safe in pregnancy?

Answer 29

o Increased risk of postnatal adaptation syndrome. HTN risk – pre-eclampsia, but should be ok and breastfeeding fine.

Question 30

Are antipsychotics safe in pregnancy?

Answer 30

o If stable and likely to relapse without in pregnancy, advise to continue (NICE). o Atypicals - breast feeding should be OK. o Don’t breastfeed on clozapine – risk of agranulocytosis. o Olanzepine and quetiapine best. o Increased prolactin not great for fertility so may switch to atypical.

Question 31

Are mood stabilisers safe in pregnancy?

Answer 31

o Patients with BAD have a 25% risk of developing PPP if not on mood stabiliser o Valproate = MAJOR TERATOGEN!! – NOT FOR WCBP (women of child bearing potential) o Lithium = increases risk of CV defects from 1% to 2-4%  So benefits of lithium may outweigh minor teratogenic effects  Up to patient

Question 32

Define dysthymia

Answer 32

A chronic state of low mood, usually with an insidious onset and lasting at least two years

Question 33

define euthymia

Answer 33

Happy, contented mood

Question 34

define mood

Answer 34

A word used to describe sustained and pervasive emotions

Question 35

define affect

Answer 35

Short-lived observable pattern of behavior that expresses the subjective emotional state of an individual. It is subject to variation over brief periods of time.

Question 36

define alexithymia

Answer 36

An inability to verbally express one’s emotions

Question 37

define anhedonia

Answer 37

Inability to enjoy anything in life or even get accustomed satisfaction from everyday events.

Question 38

define psychomotor retardation

Answer 38

The subject sits abnormally still or walks abnormally slowly or takes a long time to initiate movement.

Question 39

define flight of ideas

Answer 39

Rapid flow of thought, manifested by accelerated speech with abrupt changes between topics, although there is often some link. Loss of normal structure of thought appearing illogical or muddled. Sometimes seen in manic patients.

Question 40

define pressure of speech

Answer 40

The subject talks too much. There seems to be undue pressure to get the words out. He speaks too fast, his voice is too loud and unnecessary words are added

Question 41

define depersonalisation

Answer 41

A peculiar change in the awareness of self in which patient feels as if they are not real and detached. May feel they’ve changed and that the world around them is vague, dreamlike or lacking in significance. Retains some understanding and knows condition is abnormal.

Question 42

define derealisation

Answer 42

The subject experiences his surrounding as unreal. An office or bus or a street seems like a stage set with actors, rather than real people going about their business. Everything seems colourless, artificial and dead. The subject retains a measure of understanding and knows that the condition is abnormal

Question 43

define illusion

Answer 43

A false perception of a real stimulus.

Question 44

define illusion of completion

Answer 44

Brain completes shapes

Question 45

define affect illusion

Answer 45

Sensory stimulus is real but your affect affects the way your brain understands it. E.g. if you’re scared

Question 46

define paridolic illusion

Answer 46

Sensory is real, but brain understands it in a different way. Finding patterns where they don’t exist e.g. in pancakes

Question 47

define pseudo-hallucination

Answer 47

A perceptual experience, which is figurative, not concretely real and occurs in inner subjective space, not in external objective space. It has the quality of an idea. Vivid enough sensory experience to be regarded as a hallucination but recognized by the subject not to be a result of external stimuli and therefore not real.

Question 48

define hallucination

Answer 48

A perception, which occurs in the absence of a stimulus. It is false but to the person experiencing it, it has the full force and impact of a real perception and is consequently indistinguishable from real life. 1. Occurs in the outer space 2. Not shared by others 3. Not under your control 4. Omnipresent 5. Impact on behaviour/ affect

Question 49

define thought echo

Answer 49

The subject experiences his own thoughts as if they were being spoken aloud. May not be a simple echo but subtly or grossly changed in quality.

Question 50

define thought insertion

Answer 50

The subject experiences thoughts, which are not his own intruding into his mind. In the most typical case the alien thoughts are said to have been inserted into the mind from outside, by means of radar telepathy or some other means.

Question 51

define thought withdrawal

Answer 51

The subject says his thoughts have been removed from his head by an external agency so that he has no thoughts (often able to describe the sensation of the thoughts leaving)

Question 52

define thought broadcast

Answer 52

The subject experiences his thoughts are being shared with people e.g. by telepathy, TV, radio

Question 53

define delusions of control/passivity

Answer 53

Subject believes their thoughts/actions/feelings are not their own. They believe they are being controlled from outside. E.g. someone else’s words are coming out of their mouth.

Question 54

define delusional perception

Answer 54

Sensory stimulus is real. Delusional thought attached. A type of primary delusion. This is present when the patient receives a normal perception which is then interpreted with delusional meaning and has immense personal meaning e.g. on seeing a traffic light change from red to green, a man declared he was the King of Mars.

Question 55

define negative symptoms

Answer 55

Cluster of symptoms that often occur together in chronic schizophrenia: Poverty of speech, flat affect, poor motivation and poor attention. May result in low activity/ poor self-care.

Question 56

define clouding of consciousness

Answer 56

This represents a step down from normal alertness. There is deterioration in thinking, attention, perception and memory and usually drowsiness and reduced awareness of environment.

Question 57

define lability

Answer 57

The subject’s affect is rapidly changeable and there are marked fluctuations. May be cheerful and smiling then shortly after crying. In its extreme form we may use the word emotional incontinence.

Question 58

define delusion

Answer 58

A fixed, firmly held belief that is held with unshakable conviction despite overwhelming evidence to the contrary and cannot be explained by the subject’s cultural or religious background.

Question 59

define nihilistic delusions

Answer 59

Delusion of extreme negativity – no longer existing, about to die or even being dead. About to experience a terrible doom.

Question 60

define grandiose delusions

Answer 60

Delusions of being of special status or significance, or having special powers or attributes, or a special mission or purpose.

Question 61

define aphasia

Answer 61

No speech, inability to produce words orally

Question 62

define concrete thinking

Answer 62

Inability to understand abstract ideas or concepts, literalness of understanding or expression

Question 63

define second person auditory hallucinations

Answer 63

“You’re going to die, you’re going to die”

Question 64

define third person auditory hallucinations

Answer 64

“The voices are talking to each other about me, they say I am evil and mad”

Question 65

define ideas of reference

Answer 65

Delusional belief that innocuous events or coincidences are directly linked and have personal significance.

Question 66

define loosening of associations

Answer 66

Loss of normal, structured thinking

Question 67

define neologisms

Answer 67

New words with no real meaning

Question 68

define perseveration

Answer 68

The repetition of a particular response (e.g. phrase, word, utterance, gesture) despite the absence or cessation of the stimulus. May occur in organic brain disorders.

Question 69

define tangentiality

Answer 69

Going off on a tangent

Question 70

define circumstantiality

Answer 70

Talks around the topic for ages and never gets to the point

Question 71

define echolalia

Answer 71

The repetition of phrases, words or parts of words. Echolalia may be a sign of autism, another neurological condition, a visual impairment or a developmental disability.