Search This Blog

 


Risk assessment

Risk assessment is a crucial part of every psychiatric assessment.

Consider:

Who is at risk?

What is the nature of the risk?

What is the likelihood of the risk?

The person usually at risk, if anyone, is the patient themselves.

The risk posed to others by people with mental disorder must

Putting it all together: clinical vignettes • 325

16

Psychiatric rating scales

The use of psychiatric rating scales as clinical tools in psychiatric

assessment is increasing. Most were developed in research

studies to make a confident diagnosis or to measure change in

severity of illness. Some require special training; all must be used

sensibly. In general, scales are too inflexible and limited in scope

to replace a well-conducted standard psychiatric interview but

they can be useful adjuncts for screening, measuring response

to treatment or focusing on particular areas.

In routine practice, scales are most widely used to assess

cognitive function when an organic brain disorder is suspected.

They include:

Abbreviated Mental Test (AMT): takes less than 5 minutes

(Box 16.11)

Mini-Mental State Examination (MMSE) or Montreal

Cognitive Assessment (MoCA): takes 5–15 minutes.

Well-known instruments assessing areas other than cognition

include:

general morbidity:

• General Health Questionnaire (GHQ)

mood disorder:

• Hospital Anxiety and Depression Scale (HADS)

• Beck Depression Inventory (BDI)

alcohol:

• CAGE questionnaire (Box 16.12)

• FAST questionnaire (Box 16.13).

Putting it all together: clinical vignettes

Examples in practice are provided in Boxes 16.14–16.17.

as far as possible by visual corrections, hearing aids and

interpreters.

The central matters to be assessed are essentially cognitive:

can the patient make, understand, remember and communicate

decisions about medical treatment or other options before them?

Determining that a patient lacks capacity for a particular

decision leads to the next stage: making that decision on their

behalf. The key principles here are to ensure that any treatment

proposed must benefit the patient and be the least restrictive

option available; it should take account of any wishes the patient

has previously expressed, as well as the views of family members

and any other relevant others (such as nursing home staff).

The physical examination

Physical and mental disorders are associated, so always consider

the physical dimension in any patient presenting with a psychiatric

disorder, and vice versa. The setting and the patient’s age, health

and mode of presentation will determine the extent of physical

assessment required.

In psychiatric settings, general physical observation, coupled

with basic cardiovascular and neurological examination, will usually

suffice. Bear in mind that some physical disorders can present

with psychiatric symptoms (such as thyrotoxicosis manifesting

as anxiety – look for exophthalmos, lid lag, goitre, tachycardia

and so on). For older patients with multiple medical problems, or

those with alcohol dependence and associated physical harm,

a more detailed examination is clearly needed.

In primary care and acute hospital settings, patients will

usually undergo physical examination tailored to the presenting

problem, but it is important to be aware that some psychiatric

disorders can present with physical symptoms, such as chest

pain and transient neurological symptoms as manifestations of

panic attacks.

Collateral history

Collateral history is important whenever assessment is limited by:

physical illness, acute confusional state or dementia

severe learning disability or other mental disorder impairing

communication

disturbed, aggressive or otherwise uncooperative

behaviour.

Sources of third-party information will usually include family and

other carers, as well as past and present general practitioners

and other health professionals. Previous psychiatric assessments

are particularly valuable when a diagnosis of personality disorder

is being considered, as this depends more on information about

behaviour patterns over time than the details of the current

presentation (Box 16.10).

16.10 Personality disorder: definition

Patterns of experience and behaviour that are:

• pathological (i.e. outside social norms)

• problematic (for the patient and/or others)

• pervasive (affecting most or all areas of a patient’s life)

• persistent (adolescent onset, enduring throughout adult life and

resistant to treatment)

From Hodkinson HM. Evaluation of a mental test score for assessment of mental

impairment in the elderly. Age and Ageing 1972; 1(4):233–238, by permission

of Oxford University Press.

16.11 The Abbreviated Mental Test

• Age

• Date of birth

• Time (to the nearest hour)

• Year

• Hospital name

• Recognition of two people, e.g. doctor, nurse

• Recall address

• Dates of First World War (or other significant event)

• Name of the monarch (or prime minister/president as appropriate)

• Count backwards 20–1

Each question scores 1 mark; a score of 8/10 or less indicates

confusion.

16.12 The CAGE questionnaire

• Cut down: Have you ever felt you should cut down on your drinking?

• Annoyed: Have people annoyed you by criticising your drinking?

• Guilty: Have you ever felt bad or guilty about your drinking?

• Ever: Do you ever have a drink first thing in the morning to steady

you or help a hangover (an ‘eye opener’)?

Positive answers to two or more questions suggest problem

drinking; confirm this by asking about the maximum taken.

326 • The patient with mental disorder

16.14 Clinical vignette: overdose

A 19-year-old woman attends the accident and emergency

department, having taken a medically minor overdose. She has

presented in this way three times in the last 2 years. She needs no

specific medical treatment.

Your assessment should concentrate first on the circumstances of

the overdose and her intentions at the time. Collateral information

should include assessments after previous presentations and any

continuing psychiatric follow-up. Mental state examination should

screen for any new signs of mental disorder emerging since her last

assessment, and in particular any mood problems or new psychotic

symptoms. She will clearly have undergone a detailed physical

assessment, but even if the overdose appears medically trivial, you

need to undertake a risk assessment to judge the chances of further

self-harm or completed suicide in the near future. She probably does

not need a detailed cognitive assessment or psychiatric rating scales.

16.15 Clinical vignette: confusion, agitation and hostility

An 85-year-old man in a medical ward, where he is undergoing

intravenous antibiotic treatment for a chest infection, now appears

confused, agitated and hostile, in a way not previously evident to his

family.

You need to approach him carefully to establish rapport and to

interview him as much as he will allow, while anticipating that you may

have to rely heavily on collateral information, and a mental state

examination limited to observation of appearance and behaviour. It will

be crucial to talk to his family to establish his normal level of cognition

and independence, and to the nursing staff to establish the diurnal

pattern of his problems. If there is any history of previous episodes,

acquire the results of previous assessments. He will need a

neurological examination and assessment of his cognition via a

standard scale. Risk assessment should focus on the indirect risks to

his health if he tries to leave hospital against advice, generating a view

about his detainability under mental health legislation. A capacity

assessment of his ability to consent to continuing antibiotic treatment

is required, and may result in the issue of an incapacity certificate.

16.13 The fast alcohol screening test (FAST) questionnaire

For the following questions please circle the answer that best applies

1 drink = 1

2 pint of beer or 1 glass of wine or 1 single measure of spirits

1. Men: How often do you have eight or more drinks on one occasion?

Women: How often do you have six or more drinks on one occasion?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

3. How often during the last year have you failed to do what was normally expected of you because of drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

4. In the last year, has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down?

• Never (0)

• Yes, on one occasion (2)

• Yes, on more than one occasion (4)

Scoring FAST

First stage

• If the answer to question 1 is ‘Never’, then the patient is probably not misusing alcohol

• If the answer is ‘Weekly’ or ‘Daily or almost daily’, then the patient is a hazardous, harmful or dependent drinker

• 50% of people are classified using this one question

Second stage

• Only use questions 2–4 if the answer to question 1 is ‘Less than monthly’ or ‘Monthly’:

• Score questions 1–3: 0, 1, 2, 3, 4

• Score question 4: 0, 2, 4

• Minimum score is 0

• Maximum score is 16

• Score for hazardous drinking is 3 or more

Putting it all together: clinical vignettes • 327

16

16.16 Clinical vignette: fatigue

A 35-year-old woman attends her general practitioner, presenting with

fatigue.

Assessment of possible physical causes is required, via history,

examination and appropriate blood tests, but as these proceed, the

interview should also cover possible symptoms of depression, previous

episodes, family history and recent stressors. Mental state examination

should concentrate on objective evidence of lowered mood. Formal

assessment of cognition is probably not necessary, but a standard

rating scale for mood disorder may help establish a diagnosis and a

baseline against which to measure change. Risk assessment is not a

prominent requirement, unless a depressive illness is suspected and

she reports thoughts of self-harm, or is responsible for young children,

in which case the chance of direct or indirect harm to them needs to

be considered.

16.17 Clinical vignette: paranoid thoughts

A 42-year-old man attends a psychiatric outpatient clinic for the first

time, having been referred by his general practitioner for longstanding

paranoid thoughts.

It will be particularly important to establish rapport with a patient

who is likely to be very wary. The interview needs to cover the

psychiatric history in some detail, considering substance misuse, family

history of mental illness and a full personal history in particular. Mental

state examination should explore the paranoid thoughts in detail, to

establish whether they are preoccupations or overvalued ideas

(suggesting a personality disorder), or delusions (suggesting a

psychotic illness). Risk assessment should concentrate on the risk to

others about whom the patient has paranoid fears. Neither detailed

cognitive assessment nor a specific rating scale is likely to add much

to the initial assessment.

OSCE example 1: Assessing suicidal risk

Miss Gardiner, 27 years old, presented to the accident and emergency department the previous day after taking an overdose of paracetamol while

intoxicated with alcohol. She has undergone treatment with acetylcysteine overnight and is now medically fit for discharge.

Please assess her risk of self-harm and suicide

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to gain rapport.

• Enquire how she is feeling physically (specifically asking about nausea, vomiting and abdominal pain).

• Tactfully introduce the subject of the overdose.

• Establish the number and type of tablets taken.

• Establish how much alcohol she drank, whether this was with the tablets (to ‘wash them down’) or whether she was already intoxicated at the time

of the overdose.

• Clarify the circumstances. Who else was present or expected? Did she write a note or otherwise communicate what she had done or was planning

to do?

• Clarify how she was found and either came or was brought to hospital.

• Explore recent or chronic stressors.

• Establish her intent at the time of the overdose. Did she expect to die? Is that what she wanted?

• Confirm her view now. Does she still wish to die? Does she have any thoughts about another overdose or other form of self-harm?

• Establish relevant past history. Are there any previous overdoses? Any previous or continuing psychiatric follow-up?

• Confirm whether she has parental or caring responsibilities for young children. Tactfully enquire about any thoughts of harming them.

• Establish who will be with her when she leaves hospital.

• Thank the patient and clean your hands.

Summarise your findings

The risk assessment should concentrate most on the short-term risk of suicide.

Advanced level comments

More advanced students would be expected to tabulate short- and long-term risk of both suicide and further self-harm, and to quote the risk of

completed suicide in the first year after an act of self-harm (1–2%).

328 • The patient with mental disorder

OSCE example 2: Assessing delirium

Mr Duncan, 82 years old, is admitted to an orthopaedic ward after falling and breaking his hip. Forty-eight hours after surgery he became restless and

agitated overnight, pulling out his intravenous line. He is now settled and cooperative.

Please assess the likely cause of this episode

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to establish rapport.

• Enquire how he is feeling physically (specifically asking about pain, fever, constipation, and urinary and respiratory symptoms).

• Establish his awareness of where he is, why he is there and how long he has been in hospital.

• Ask how much he remembers of the night’s events and enquire specifically about any recollection of hallucinations or persecutory fears.

• Enquire about any continuing hallucinations or fears.

• Ask about any previous similar episodes.

• Clarify how active he was before his fall, and whether there is any awareness of memory impairment leading up to it.

• Ask about alcohol intake.

• Administer simple tests of cognitive function, especially of attention and memory (advanced performers should know the Abbreviated Mental Test

questions).

• Undertake a basic physical examination, assessing for tremor, ophthalmoplegia and nystagmus.

• Gain the patient’s permission to speak to his next of kin, general practitioner and others.

• Thank the patient and clean your hands.

Summarise your findings

The diagnosis is delirium, with further enquiries needed to establish the likely cause (which may be alcohol withdrawal, given the timing), as well as

the possibility of pre-existing cognitive impairment as a vulnerability factor.

Integrated examination sequence for the psychiatric assessment

• Review the relevant information to clarify the reason for referral or mode of self-presentation.

• Establish rapport to reduce distress and assist assessment.

• Cover the key headings for the history (presenting symptoms, systematic review, past medical and psychiatric history, current medication, substance

misuse, family history, personal history).

• Cover the headings for the personal history (childhood development, losses and experiences, education, occupation, financial circumstances,

relationships, partner(s) and children, housing, leisure activities, hobbies and interests, forensic history).

• Make the extent, order and content of the assessment appropriate to the presentation and setting.

• Observe closely to gain objective evidence of mental state, especially non-verbal information.

• Cover the headings for the mental state examination systematically (appearance and behaviour, speech, mood, thought form and content,

perceptions, cognition and insight).

• Use brief formal tests to assess cognitive function (Abbreviated Mental Test, Mini-Mental State Examination, Montreal Cognitive Assessment).

• Consider your own emotional response to your patient.

• Consider standardised rating scales as a screening tool (and sometimes to monitor progress).

• Undertake physical examination as appropriate to the setting and the presentation.

• Gather further background information from other sources to the degree necessary (with permission).

• As well as a diagnosis and management plan, be sure to consider:

• assessment of risk to self or others

• capacity to take decisions

• need to use mental health or incapacity legislation.

17

The frail elderly patient

Andrew Elder

Elizabeth MacDonald

Assessment of the frail elderly patient 330

Factors influencing presentation and history 330

The history 331

The presenting symptoms 331

Common presenting symptoms 331

Past medical history 331

Drug history 331

Family history 332

Social and functional history 332

Systematic enquiry 332

The physical examination 333

General examination 333

Systems examination 334

Functional assessment 335

Interpretation of the findings 337

OSCE example 1: History in a frail elderly patient with falls 337

OSCE example 2: Examination of an acutely confused frail

elderly patient 337

Integrated clinical examination for the frail elderly patient 338

330 • The frail elderly patient

Factors influencing presentation

and history

Classical patterns of symptoms and signs still occur in the frail

elderly, but modified or non-specific presentations are common

due to comorbidity, drug treatment and ageing itself. As the

combination of these factors is unique for each individual, their

presentations will be different. The first sign of new illness may

be a change in functional status: typically, reduced mobility,

altered cognition or impairment of balance leading to falls.

Common precipitants are infections, changes in medication and

metabolic derangements but almost any acute medical insult can

produce these non-specific presentations (Fig. 17.1). Each of

these presentations should be explored through careful history

taking, physical examination and functional assessment.

Disorders of cognition, communication and mood are so

common that they should always be considered at the start of

the assessment of a frail older adult.

Communication difficulties,

cognition and mood

Communication can be challenging (Box 17.2). The history

can be incomplete, difficult to interpret or misleading, and the

whole assessment, including physical examination, may be

time-consuming.

Whenever possible, assess the patient somewhere quiet with

few distractions. Make your patient comfortable and ensure they

understand the purpose of your contact. Provide any glasses,

hearing aids or dentures that they need and help them to switch

Assessment of the frail elderly patient

Comprehensive geriatric assessment is an evidence-based

process that improves outcomes. It involves taking the history

from the patient and, with the patient’s consent, from a carer

or relative, followed by a systematic assessment of:

cognitive function and mood

nutrition and hydration

skin

pain

continence

hearing and vision

functional status.

The extent and focus of the assessment depend on the clinical

presentation. In non-acute settings such as the general practice

or outpatient clinic or day hospital, focus on establishing what

diseases are present, and also which functional impairments

and problems most affect the patient’s life.

In acute settings such as following acute hospital referral,

focus on what has changed or is new. Seek any new symptoms

or signs of illness and any changes from baseline physical or

cognitive function.

The complexity of the problems presented, and the need for

comprehensive and systematic analysis, mean that assessment

is divided into components undertaken at different times, by

different members of the multiprofessional team (Box 17.1).

There is no specific age at which a patient becomes

‘elderly’; although age over 65 years is commonly used as the

definition, this has no biological basis, and many patients who

are chronologically ‘elderly’ appear biologically and functionally

younger, and vice versa.

Frailty becomes more common with advancing age and is

likely to be a response to chronic disease and ageing itself. A frail

elderly person typically suffers multimorbidity (multiple illnesses)

and has associated polypharmacy (multiple medications). They

often have cognitive impairment, visual and hearing loss, low

bodyweight and poor mobility due to muscular weakness, unstable

balance and poor exercise tolerance. Their general functional

reserve and the capacity of individual organs and physiological

systems are impaired, making the individual vulnerable to the

effects of minor illness.

17.1 The multiprofessional team

Professional Key roles in assessment of

Physician Physical state, including diagnosis

and therapeutic intervention

Psychiatrist Cognition, mood and capacity

Physiotherapist Mobility, balance, gait and falls risk

Occupational therapist Practical functional activities

(self-care and domestic)

Nurse Skin health, nutrition and continence

Dietician Nutrition

Speech and language therapist Speech and swallowing

Social worker Social care needs

,QIHFWLRQ 0HWDEROLF

SUREOHPV

'UXJV 2WKHU

SUHFLSLWDQWV

)XQFWLRQDOGHFRPSHQVDWLRQRIWKHIUDLOHOGHUO\DGXOW

,PPRELOLW\ 'HOLULXP )DOOV

Fig. 17.1 Functional decompensation in frail elderly people.

17.2 Communication difficulties: the seven Ds

Problem Comment/causes

Deafness Nerve or conductive

Dysphasia Most commonly due to stroke disease but sometimes

a feature of dementia

Dysarthria Cerebrovascular disease, motor neurone disease,

Parkinson’s disease

Dysphonia Parkinson’s disease

Dementia Global impairment of cognitive function

Delirium Impaired attention, disturbance of arousal and

perceptual disturbances

Depression May mimic dementia or delirium







 The main difference between them is that delusions either

lack a cultural basis for the belief or have been derived from

abnormal psychological processes.

Overvalued ideas

These are usually beliefs of great personal significance. They

fall short of being full delusions but are abnormal because of

their effects on a person’s behaviour or wellbeing. For example,

in anorexia nervosa, people may still believe they are fat when

they are seriously underweight – and then respond to their belief

rather than their weight, by further starving themselves.

Delusional beliefs

These beliefs also matter greatly to the person, resulting in

powerful emotions and important behavioural consequences;

they are always of clinical significance. They are classified by

their content, such as:

paranoid

religious

grandiose

hypochondriacal

of guilt

of love

of jealousy

of infestation

of thought interference (broadcasting, insertion and

withdrawal)

of control.

Bizarre delusions are easy to recognise, but not all delusions

are weird ideas: a man convinced that his partner is unfaithful

may or may not be deluded. Even if a partner were unfaithful,

it would still amount to a delusional jealousy if the belief were

held without evidence or for some unaccountable reason, such

as finding a dead bird in the garden.

may be understandable but unusually rapid, as in the flight of

ideas that characterises hypomania, or unduly ‘single track’ and

perseverative, as in some cases of dementia. Sometimes thinking

appears to be very circumstantial, and the patient hard to pin

down, even when asked simple questions.

More severe disruption of the train of thought is termed

loosening of associations or formal thought disorder, in which

the patient moves from subject to subject via abrupt changes of

direction that the interviewer cannot follow. This is a core feature

of schizophrenia. Concrete thinking, in the sense of difficulty

handling abstract concepts, is a common feature of dementia,

and can be assessed by asking the patients to explain the

meaning of common proverbs.

It may help to illustrate your assessment with verbatim examples

from the interview, chosen to illustrate the patient’s manner of

thinking and speaking.

Thought content

Thought content refers to the main themes and subjects occupying

the patient’s mind. It will become apparent when taking the history

but may need to be explored further via specific enquiries. It

may broadly be divided into preoccupations, ruminations and

abnormal beliefs. These are defined in Boxes 16.7 and 16.8.

Preoccupations

Preoccupations occur in both normal and abnormal mood states.

Sadly dwelling on the loss of a loved one is entirely normal in

bereavement; persisting disproportionate guilty gloom about the

state of the world may be a symptom of depression.

Ruminations

These are preoccupations that are in themselves abnormal –

and therefore symptoms of mental disorder – by reason of

repetition (as in obsessional disorders) or groundlessness (as

in hypochondriasis).

Abnormal beliefs

These beliefs fall into two categories: those that are not diagnostic

of mental illness (such as overvalued ideas, superstitions and

magical thinking) and those that invariably signify mental illness

(that is, delusions).

16.7 Thought content: definitions

Term Definition

Hypochondriasis Unjustified belief in suffering from a particular

disease in spite of appropriate examination and

reassurance

Morbid thinking Depressive ideas, e.g. themes of guilt, burden,

unworthiness, failure, blame, death, suicide

Phobia A senseless avoidance of a situation, object or

activity stemming from a belief that has caused

an irrational fear

Preoccupation Beliefs that are not inherently abnormal but which

have come to dominate the patient’s thinking

Ruminations Repetitive, intrusive, senseless thoughts or

preoccupations

Obsessions Ruminations that persist despite resistance

16.8 Abnormal beliefs: definitions

Term Definition

Delusion An abnormal belief, held with total conviction, which

is maintained in spite of proof or logical argument to

the contrary and is not shared by others from the

same culture

Delusional

perception

A delusion that arises fully formed from the false

interpretation of a real perception, e.g. a traffic light

turning green confirms that aliens have landed on

the rooftop

Magical

thinking

An irrational belief that certain actions and outcomes

are linked, often culturally determined by folklore or

custom, e.g. fingers crossed for good luck

Overvalued

ideas

Beliefs that are held, valued, expressed and acted

on beyond the norm for the culture to which the

person belongs

Thought

broadcasting

The belief that the patient’s thoughts are heard by

others

Thought

insertion

The belief that thoughts are being placed in the

patient’s head from outside

Thought

withdrawal

The belief that thoughts are being removed from the

patient’s head

The mental state examination • 323

16

when going to sleep (hypnagogic) or waking up (hypnopompic).

Hallucinations are categorised according to their sensory modality

as auditory, visual, olfactory, gustatory or tactile.

Any form of hallucination can occur in any severe mental

disorder. The most common are auditory and visual hallucinations,

the former associated with schizophrenia and the latter with

delirium. Some auditory hallucinations are characteristic of

schizophrenia, such as voices discussing the patient in the

third person or giving a running commentary on the person’s

activities (‘Now he’s opening the kitchen cupboard’). Ask, for

example, ‘Do you ever hear voices when nobody is talking?’

and ‘What do they say?’

Pseudohallucinations are common. The key distinction from

a true hallucination is that they occur within the patient, rather

than arising externally. They have an ‘as if’ quality and lack the

vividness and reality of true hallucinations. Consequently, the

affected person is not usually distressed by them, and does

not normally feel the need to respond, as often happens with

true hallucinations.

Cognition

If the history and observation suggest a cognitive deficit, it must

be evaluated by standard tests. History, observation, MSE and

rating scales (see later) are then used together to diagnose and

distinguish between the ‘3Ds’ (dementia, delirium and depression),

which are common in the elderly and in hospital inpatients.

Core cognitive functions include:

level of consciousness

orientation

memory

attention and concentration

intelligence.

Level of consciousness

Mental disorders are rarely associated with a reduced (or clouded)

level of consciousness, such as drowsiness, stupor or coma.

The exception is delirium (which is both a physical and a mental

disorder), where it is common.

Orientation

This is a key aspect of cognitive function, being particularly

sensitive to impairment. Disorientation is the hallmark of

the ‘organic mental state’ found in delirium and dementia.

Abnormalities may be evident during the interview but some

patients are adept at hiding them in social interactions. Check

the patient’s orientation to time, place and person by evaluating

their knowledge of the current time and date, recognition of

where they are, and identification of familiar people.

Memory

Memory function is divided into three elements:

Registration is tested by asking the patient to repeat after

you the names of three unrelated objects (apple, table,

penny); any mistake is significant. Alternatively, in the digit

span test, ask the patient to repeat after you a sequence

of random single digit numbers. Make sure you speak

slowly and clearly. A person with normal function can

produce at least five digits.

Short-term memory (where short-term is defined as a

matter of minutes) is tested by giving the patient some

Delusions can sometimes be understood as the patient’s way

of trying to make sense of their experience, while the content of

the delusions often gives a clue that may help type the underlying

illness: for example, delusions of guilt suggest severe depression,

whereas grandiose delusions typify mania.

Some delusions are characteristic of schizophrenia. They

include a delusional perception (or primary delusion) and ‘passivity

phenomena’: namely, the belief that thoughts, feelings or acts

are no longer controlled by a person’s own free will.

Perceptions

People normally distinguish between their inner and outer worlds

with ease: we know what is real, what reality feels like, and what

resides in our ‘mind’s eye’ or ‘mind’s ear’. In mental illness this

distinction can become disrupted, so that normal perceptions

become unfamiliar, while abnormal perceptions seem real.

Abnormal perceptions are assessed via the history and specific

enquiries, backed up by observation. They fall into several

categories, defined in Box 16.9.

Perceptions may be altered (as in sensory distortions or illusions)

or false (as in hallucinations and pseudohallucinations). In a third

category, what is altered is not a perception in a specific sensory

modality but a general sense of disconnection and unreality

in oneself (depersonalisation), the world (derealisation) or both.

People find depersonalisation and derealisation intensely

unpleasant but hard to describe. They may occur in association

with severe tiredness or intense anxiety but can also arise in most

types of mental illness. Ask, for example, ‘Have you ever felt that

you were not real or that the world around you wasn’t real?’

With altered perceptions there is a real external object but its

subjective perception has been distorted. Sensory distortions,

such as unpleasant amplification of light (photophobia) or sound

(hyperacusis), can occur in physical diseases, but are also

common in anxiety states and drug intoxication or withdrawal.

Diminution of perceptions, including pain, can occur in depression

and schizophrenia.

Illusions, in which, for example, a bedside locker is misperceived

as a threatening animal, commonly occur among people with

established impairment of vision or hearing. They are also found

in predisposed patients who are subjected to sensory deprivation,

notably after dark in a patient with clouding of consciousness.

They are suggestive of an organic illness such as delirium,

dementia or alcohol withdrawal.

True hallucinations arise without external stimuli. They usually

indicate severe mental illness, although they can occur naturally

16.9 Perceptions: definitions

Term Definition

Depersonalisation A subjective experience of feeling unreal

Derealisation A subjective experience that the surrounding

environment is unreal

Hallucination A false perception arising without a valid

stimulus from the external world

Illusion A false perception that is an understandable

misinterpretation of a real stimulus in the

external world

Pseudohallucination A false perception that is perceived as part

of one’s internal experience

324 • The patient with mental disorder

be neither overstated nor ignored. Any others at risk are most

likely to be family or, less commonly, specific individuals (such

as celebrities in cases of stalking) or members of specific groups

(defined by age, ethnicity, occupation and so on). Sometimes the

risk applies non-specifically to strangers, or to anyone preventing

the patient from achieving their goals.

There may be direct risk to life and limb (as in suicide, self-harm

or violence to others), or it may be an indirect risk, either to health

(through refusal of treatment for physical or mental illness) or

welfare (through inability to provide basic care – food, warmth,

shelter, hygiene – for oneself or one’s dependents). The risk may

be imminent, as in a patient actively attempting self-harm, or

remote, as in a patient refusing prophylactic medical treatment.

Direct risks tend to be imminent and indirect risks remote, although

this is not always so. A patient declining renal dialysis because

their depression makes them feel unworthy is at imminent but

indirect risk of death. Finally, the likelihood of the risk may range

from near certainty to hypothetical possibility.

A risk assessment should readily distinguish between cases

where there is an imminent, direct and near-certain risk to the

patient’s life (such as a man actively trying to throw himself from

the window to escape delusional persecutors), and those where

any risks apply to the welfare of other people, at some point

in the future, and amount to possibilities (such as a depressed

woman who may be neglecting her frail elderly father). The former

case calls for urgent intervention, probably via mental health

legislation; the latter requires engagement over time, preferably

in a voluntary way.

While all psychiatric evaluations require some assessment of

risk, it should be considered in depth whenever the presentation

includes acts or threats of self-harm or reports of command

hallucinations, the past history includes self-harm or violent

behaviour, the social circumstances show a recent, significant

loss, or the mental disorder is strongly associated with risk (as

in severe depression).

Assessing suicidality is the element of risk assessment that is

most often needed. If a patient presents after an act of self-harm

or overdose, the questions arise naturally (‘What did you want

to happen when you took the tablets? Did you expect to die?

Is that what you wanted? How do you feel about that now? Do

you still feel you’d be better off dead? Have you had thoughts

about doing anything else to harm yourself?’).

In other circumstances the subject will need to be introduced,

but do not fear that you may be putting ideas in the patient’s

mind (‘You’ve told me how bad you have been feeling. Have

you ever felt life is not worth living? Have you had any thoughts

about ending your life? How close have you come? What has

stopped you acting on those thoughts so far?’).

Capacity

Assessing capacity is a skill required of all doctors and should not

be delegated to psychiatrists. The legal elements vary between

jurisdictions but there are key clinical principles in common.

The first is the presumption of capacity: clinicians should treat

patients as retaining capacity until it is proven that they have lost

it. Secondly, capacity is decision-specific: patients may not be

able to understand the risks and benefits of complex medical

treatment options, while retaining the ability to decide whether

or not to enter a nursing home. Thirdly, residual capacity should

be maximised: if a patient’s ability to understand is impaired by

sensory deficits or language barriers, these should be corrected

new information; once this has registered, check retention

after 5 minutes, with a distracting task in between. Do the

same with the names of three objects; any error is

significant. Alternatively, use a six-item name and address

(in the format: Mr David Green, 25 Sharp Street, Durham).

More than one error indicates impairment.

Long-term memory is assessed mainly from the personal

history. Gaps and mistakes are often obvious but some

patients may confabulate (that is, fill in the gaps with

plausible but unconsciously fabricated facts), so check the

account with a family member or other informant if

possible. Confabulation is a core feature of Korsakoff’s

syndrome, a complication of chronic alcoholism. Failing

long-term memory is characteristic of dementia, although

this store of knowledge can be remarkably intact in the

presence of severe impairment of other cognitive functions.

Impaired attention and concentration

These occur in many mental disorders and are not diagnostic.

Impaired attention is observed as increased distractibility, with

the patient responding inappropriately to intrusive internal events

(memories, obsessions, anxious ruminations) or to extraneous

stimuli, which may be either real (a noise outside the room) or

unreal (auditory hallucinations).

Concentration is the patient’s ability to persist with a mental

task. It is tested by using simple, repetitive sequences, such as

asking the patient to repeat the months of the year or days of

the week in reverse, or to do the ‘serial 7s’ test, in which 7 is

subtracted from 100, then from 93, then 86 and so on. Note

the finishing point, the number of errors and the time taken.

Intelligence

This is estimated clinically from a combination of the history

of educational attainment and occupations, and the evidence

provided at interview of vocabulary, general knowledge, abstract

thought, foresight and understanding. If in doubt as to whether

the patient has a learning disability, or if there is a discrepancy

between the history and presentation, a psychologist should

formally test IQ.

Insight

Insight is the degree to which a patient agrees that they are

ill. It can be broken down into the recognition that abnormal

mental experiences are in fact abnormal, agreement that these

abnormalities amount to a mental illness, and acceptance of the

need for treatment. Insight matters, since a lack of it often leads

to non-adherence, and sometimes to the need for compulsory

detention. You might ask ‘Do you think anything is wrong with

you’ or ‘If you are ill, what do you think needs to happen to

make you better?’

mcq general

 

Search This Blog