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1

differentiate between suicide and deliberate self harm

suicide = intentional self-inflicted death
DSH = intention, non-fatal self-inflicted harm

2

what factors make someone more likely to attempt suicide?

mental illness, in particular:
depression
bipolar disorder
schizophrenia
alcohol/substance misuse
emotionally unstable personality disorder
anorexia nervosa

also:
chronic pain/disease
availability of means (ligature points, firearms, paracetamol pack size reductions)
family history of suicide
lack of social support or recent adverse event (bereavement, loss of job/relationship)

3

give some suicide prevention strategies

- detect and treat mental illness
- be alert to risk and respond to it - lots of people see GP in the weeks preceding suicide
- safer prescribing - avoid prescribing drugs with high overdose toxicity to patients with suicide risk
- urgent hospitalisation/detention for people with suicide intent
- careful management of DSH - high risk of future completed suicide
- tackle population factors like unemployment, access to means

4

describe epidemiological differences between who self harms and who completes suicide (e.g. by age, sex etc)
also give some of the common methods for each

suicide - M > F, older single men big risk. hanging most common method in UK, others incl jumping in front of train/car, poisoning
DSH - F > M, more common in women, under 35s, lower social classes and single/divorced
means - mostly drug overdose or physical self-injury e.g. cutting or stabbing

5

give four different categories that motives behind DSH can broadly be categorised into

- desire to interrupt a sequence of events seen as inevitable or undesirable
- need for attention
- attempt to communicate
- true wish to die

6

what are indicators of high risk in a suicide/DSH history

leaving a note, making a will, continued determination to die, marked feelings of hopelessness, precautions taken against discovery, high lethality risk (either objective, or patient believes! i.e. 3 paracetamol is high risk if patient believed that's lethal dose)

also if older, male, unemployed, socially isolated
hx of previous attempts/DSH - biggest indicator of future completed suicide

7

list the different options for management of DSH

MEDIATE
Medically stabilise
Establish rapport
Diagnose and treat mental illness
Iatrogenic risk - prescribe safely (e.g. SSRIs rather than tricyclics)
Assess likelihood of recurrence:
Thoughts might return? = make a plan
Evaluate social problems

basically want to reduce risk of them doing it again, ensure treatment of underlying mental illness is either started or continued, address any social problems and make sure they know what to do if they feel like they might do it again - e.g. come to A&E, contact crisis team - do they need admission?
DBT good for repeated DSH in EUPD

8

what are the main areas to consider in a psychiatric risk assessment?

risk to self
risk to others
risk of self neglect/accidental harm
vulnerability to abuse

risk should be regularly reviewed as it fluctuates
remember past behaviour biggest predictor of future risk!!

9

what would you document when assessing risk to self?

- current suicidal thoughts, plans and intent
- anything that prevents patient acting on these thoughts eg. family, religion (protective factors)
- prev eps of DSH - circumstances, methods, management
- factors predisposing to DSH/suicide (FHx, social isolation, substance misuse etc)
- hx of disengagement from support services, whether they're currently willing to engage

in MSE look for thoughts of hopelessness/worthlessness, command hallucinations inciting self-harm

10

what would you document when assessing risk to other?

- acts or threats of violence - to whom, frequency, severity, methods used, any serious harm resulting
- deliberate arson
- sexually inappropriate behaviour
- episodes of containment (compulsory detention, treatment in hospital, secure unit, locked ward, prison, police station)
- compliance with prev and current treatment - note past disengagement

Factors increasing risk:
- recent stopping prescribed drugs
- change in use of recreational drugs
- alcohol/substance misuse
- impulsive or unpredictable behaviour
- recent stressful life events, change in personal circumstances, lack/loss of social support

in MSE:
- expressed violent intention or threats
- irritability, disinhibition, suspiciousness
- persecutory delusions
- delusions of control/passivity phenomena
- command hallucinations

11

give examples of self-neglect/accidental injury someone with mental illness could be at risk of

- malnutrition - forgetting to eat, eating out of date foods
- failure to access healthcare
- living in squalid conditions
- falls - physical frailty, drug/alcohol intoxication
- failure to take safeguards against fire/explosion e.g. cigarette burned bed sheets, leaving gas on)
- wandering, poor road safety
- accidental overdose/not taking meds
- vulnerability to crime due to leaving door open, persistently losing key or inviting strangers in

12

give examples of abuse someone with mental illness could be at risk of

abuse = single or repeated lack of appropriate action occurring within any relationship where there is an expectation of trust and which causes harm or distress to a vulnerable person
may be verbal, physical, financial or sexual, or neglect
- people in institutions are at risk
- also occurs in private homes
make sure carers aren't having to deal with verbal/physical abuse from patient

13

what acronym can you use to remember factors affection risks to vulnerable adults?

HOW SAFE?
HOme safety e.g. leaving gas on
Wandering

Self neglect e.g. poor self care
Abuse, neglect, crime vulnerability
Falls
Eating - malnutrition

14

describe steps that should be taken in immediate management of a violent patient

- consider if admission necessary, need for MHA assessment - PICU, secure ward?
- staff will be trained in breakaway techniques (to exit situation) and also in respectful restraint (talking down always first)
- medication e.g. benzodiazepines and/or antipsychotics e.g. midazolam (short acting), lorazepam (intermediate acting)
- seclusion if needed

15

what acronym can you use to remember immediate management of violence?

BE CAREFUL
Breakaway
Evaluate and talk down

Control and restraint
Assess need for medication to sedate and/or treat disorder
RE-evaluate setting - higher security?
FULly review care plan

16

what steps can be taken to prevent future violence after a violent incident?

WARN
Write risk incidents in notes
Assess in safe environment
Read documentation before assessing
Notifying professionals involved of risks

communication between agencies, good use of care plans, monitoring level specific to that patient's needs

17

in the context of a risky patient, when is it appropriate to break confidentiality?

- if aware of specific threat to named individual - must inform that person (and probably also the police)
- rarely, can justify breaking in name of public interest e.g. to assist in prevention, detection or prosecution of serious crime
- also must report significant abuse causing harm to children and vulnerable adults - to social services or police if severe

18

explain the mechanism of action of ECT

induction of a modified cerebral seizure - patient undergoes a series of these (e.g. twice a week for 4-12 sessions)
effects include (nobody really knows):
neurotransmitter release - serotonin, noradrenaline, dopamine
transient increase in blood-brain-barrier permeability
modulation of neurotransmitter receptors
synaptogenesis and neurogenesis
hypothalamic and pituitary hormone secretion

19

explain the legal aspects of ECT

if a patient with capacity refuses it, it cannot be given - not even if under section.
patient must give informed consent before each session
or can be given if:
pt lacks capacity and it doesn't conflict with advanced decision
AND it's an emergency and independent consultant has not yet assessed
OR
independent consulted appointed by mental health act commission agrees

20

what are some indications for use of ECT?

- severe depression (this is the main one)
- prolonged or severe episode of mania that doesn't respond to treatment
- catatonia
- moderate depression not responsive to multiple drug and psychological therapies

must only be used to induce fast and short-term improvements of severe symps after all other options failed
patients usually need subsequent treatment to prevent relapse

21

what are some relative contra-indications to ECT?

raised ICP
recent stroke
recent MI
unstable angina

22

how is ECT given?

patient fasts for 4 hours
anaesthetist gives short-acting anaesthetic + muscle relaxant + preoxygenation
psychiatrist then runs electric current through electrodes on head
induces seizure - lasts 20-60s, monitor EEG and movement
monitor during recovery

typically twice a week for 4-12 sessions depending on response

23

give some side effects of ECT

- cognitive impairment is the biggie - cognition should be assessed before, during and after a course of treatment
- if significant impairment - consider switching electrode placement, reducing stimulant dose or stopping treatment
also:
- anaesthetic complications
- dysrhythmias due to vagal stimulation
- post-ictal headache
- confusion
- retrograde and anterograde amnesia - difficulties in registration and recall may persist for several weeks

24

explain a bit about the newer methods of brain stimulation

transcranial magnetic stimulation (TMS) - prefrontal cortex stimulation by application of strong magnetic field - shows promise for depression
vagal nerve stimulation - used in epilepsy and refractory depression - generator implanted under skin used to electrically stimulate the nerve
deep brain stimulation - thin electrode inserted directly into brain - used in Parkinsons, research into its role in OCD

25

what are the first and second rank symptoms for schizophrenia? (ICD 10)

ICD 10 says need these for >1 month

first rank (any one = schizophrenia):
- persecutory delusions
- delusions of reference
- delusional perception
- thought insertion/withdrawal/broadcast
- passivity (made act, thought or feeling)
- somatic passivity
- third person auditory hallucinations (discussing them/running commentary)

second rank (any two)
- any persistent hallucination
-neologisms (made-up words) or other forms of disorganised speech/thought disorder
- 'negative' symptoms e.g. apathy, poverty of speech, blunted affect

26

what is 'psychosis'? give some examples of psychotic disorders

losing touch with reality - misperception of thoughts/ perceptions arising in the patient's own mind as reality - includes delusions and hallucinations - symptom rather than a diagnosis

e.g. schizophrenia, delusional disorder, schizoaffective disorder, psychotic depression and bipolar affective disorder

27

what are the positive symptoms of schizophrenia?

delusions - persecutory, or delusions of reference
hallucinations
formal thought disorder (disorganised sepech) e.g. neologisms

28

what are the negative symptoms of schizophrenia?

poverty of speech
flat affect
poor motivation
social withdrawal
lack of concern for social conventions
poor attention and memory (cognitive symptoms)

29

what are the DSM 5 criteria for schizophrenia?

at least two of following, including 1 positive symp (1-3), for at least 6 months:
1) delusions
2) hallucinations
3) disorganised speech
4) disorganised or catatonic behaviour
5) negative symptoms

30

what are the different subtypes of schizophrenia according to ICD 10 (DSM 5 doesn't have subtypes)?

- paranoid schizophrenia - most common, delusional and auditory hallucinations
- catatonic - psychomotor disturbances e.g. rigidity, posturing, echolalia, echopraxia
- hebephrenic aka disorganised - early onset, poor prognosis, irresponsible behaviour, mood inappropriate, affect incongruous e.g. lots of giggling etc, fleeting delusions and hallucinatiosn
- residual - history of one of the ones above, but currently it's mostly just negative symptoms
- simple schizophrenia - negative symps without preceding overt psychotic symptoms - rare