Approach to the patient with psychological disturbance
It is important to ensure you approach these stations with your standard opening and background questions, followed by time focusing on your psychiatric symptoms. There are many mnemonics to help you cover each of the aspects in the psychiatric history, ‘ASEPTIC’ is the one outlined below. Typically the examiner will ask you to pause around one minute before the end of the station to allow you to summarise your findings and outline your plan.
For the majority of presentations plans will need to include the following points:
- SADPERSONS score
- Capacity assessment
- Psychosocial needs assessment
- Psychiatric review/referral
- Contact with children
Psychiatric History
Introduction and acknowledgment of problem
“Hello. My name is Phil. I am one of the medical students”
“Before we start can you confirm your name and date of birth for me please?”
“Are you comfortable currently, do you need any pain relief or a drink?”
Background
“Before we explore why you are here today can I just find out a little bit more about you please?”
- Past medical history: medical; surgical; obgyn; psychiatric.
- Allergies
- Regular medications (including contraception and over the counter)
- Family history
- Social
- Smoking,
- Drinking,
- Recreational drugs,
- Employment,
- Foreign travel,
- Who do you live with?
- Children at home (any Social Services involvement?),
- Safe at home (HITS – Hurts, Insults, Threats, Shouts)?
Current problem
“Are you ok to tell me about why you have come to the hospital today?
- EXPLORE symptoms
- COVER ‘ASEPTIC’ or what ever mnemonic you use
Appearance and behaviour
- Clothes: appropriateness; style
- Personal hygiene
Speech
- Rate; volume; tone; quality
- Pressured speech
- Flight of ideas: rapid shifting; little linking associations
- Knight’s move thinking (unrealated or remotely related ideas)
- Neologisms (made up words; little sense)
- Word salad (mixture of seemingly random words)
Emotions and mood
- Low; high; angry; eccentric; spontaneous
Perceptions
- Illusions
- Delusions (grandeur)
- Hallucinations: auditory (1st or 3rd person); visual; olfactory
Thoughts
- Pre-occupations or recurring thoughts
- Persecution or paranoia
- Thought: insertion; withdrawal; broadcasting; blocking
- Control by external forces (somatic passivity)
- De-personalisation (detachment from within oneself)/
- Derealisation (detachment from within the world)
Insight
- Do they think they are unwell or that there is something wrong with them?
- If so, what?
Cognition
- Time orientation to: time; place; person
- A formal AMTS or mini-mental state examination
Summary to the examiner
- Expand more with an example as this can net you a lot of marks if you have not be explicit in your questions to date
In summary Mrs Jones has presented with X
“On my assessment her:
Appearance and behaviour is: X
Speech is: X
Emotions are: X
Perceptions: she does/does not show evidence of illusions; delusions etc
Thoughts: she does/does not show evidence of thought disorder etc
Insight: she appears/does not appear to have insight into her current problems
Cognition: I have not formally done a MMSE, however, I can do if you wish. She does appear/not appear orientated to time; place; person”
Plan
“Thank you for your time and for speaking to me.”
“I am worried about x and I think it would be useful to ask the mental health team to come and speak to you. What would you think about this? Are you happy to stay for this?”
“To complete my examination I would like to do a”:
- SADPERSONS score
- Capacity assessment
- Psychosocial needs assessment
“Does that sound reasonable to you? Do you have any questions or concerns?”
Examinations and scoring systems
Modified SADPERSONS Score
This is a 10 item score used to try and assess a person’s risk of suicide. It is divided into low, moderate and high with each category signposting to possible management strategies.
Low risk = 0-5 may be safe to discharge
Moderate risk: 5-6 consider admission
High risk: >8 probably needs admission
| S | Sex is male | YES = 1 | P | Previous Attempt | YES = 1 |
| A | Age is<45 or >65 | YES = 1 | E | Ethanol use | YES = 1 |
| D | Depression | YES = 2 | R | Rational thinking loss | YES = 1 |
| S | Single/widowed/divorced | YES = 1 | |||
| O | Organised plan | YES = 1 | |||
| N | No social support | YES = 1 | |||
| S | Stated future attempt | YES = 1 |
Abbreviated Mental Test Score (AMTS)
Scoring system use to assess older patients with dementia
Ten questions all worth one point each
Score of <6 suggests delirium or dementia
- Age
- Time to nearest hour
- Give the patient an address and ask them to repeat it at the end of the test (traditionally 42 West Street)
- Year
- Name of the hospital
- Two person recognition
- Date of birth
- Starting year of World War I
- Name of the monarch or Prime Minister
- Count backwards 20 to 1
Mini Mental State Examination
Assessing Mental Capacity
Background
The MDU, GMC and RCEM websites have good overviews of this topic. Further links can be found in Chapter 2 of this guide.
- A key principle candidates sometimes mix up is the difference between capacity and competence.
Capacity – applies to those over than 16; it is assumed and the onus is on the health care professional to disprove.
Gillick competence – applies to those under 16; it has to be proven by the young person. It is about the ability to consent to something; it can not be used to refuse something. It should not be confused with the Fraiser guidelines, which relate to matters concerning sexual health and contraception in those under 16 years.
- Those with capacity are free to make decision that we may regard as unwise
At its heart capacity is about the ability of someone to make a specific decision at a particular time. This is judged using a two stage test:
STAGE 1:
Is there evidence of an impairment or disturbance of the functioning mind or brain? (generally assessed with orientation to time, place and person)
- No – a patient older than 16 years is assumed to have capacity
- Yes – you need to move to stage two to see if you can prove they don’t have capacity
STAGE 2: A functional test to confirm the presence or absence of capacity using four questions.
Is the person able to:
- Weigh up options: pros and cons
- Understand the information relevant to the decision
- Retain the information
- Communicate their decision to others
The patient lacks capacity if unable to fulfill one or more of the questions asked.
Assessing Mental Capacity
Introduction
” Hello. My name is Phil. I am one of the medical students.”
“Before we start can you confirm your name and date of birth for me please?”
“Are you comfortable currently, do you need any pain relief or a drink?”
Explains reason for meeting
The approach is dependent on scenario presented. It may be a patient presenting on their own accord; a concerned family member or a member of staff may bring concerns to you about the patient
Example based on concerns being highlighted to you may proceed like:
“I gather you came to hospital because of…”
“The nursing staff are concerned about… and have asked me to come and talk to you, would that be ok?”
Patient understanding
“What is your understanding of what is going on and why you are in hospital?”
Capacity Assessment
Test 1: Impairment or disturbance
- “Firstly, how are you feeling in yourself at the moment?”
- “Do you feel muddled or confused?”
- “Can you tell me your name again?”
- “Where we are?”
- “What time it is?”
Test 2: Demonstrate ability to: weigh up; understand; retain and communicate
Weigh up (pros/cons)
“I want you to stay in hospital/have… because…”
“My concerns if you don’t are…”
“What do you think of this?”
“Can you tell me your reasons for not wanting this?”
Understand/retain
“So I can check we both understand one another can you summarise what my concerns for you are?”
Communicate
“Based on what we have discussed can you tell me what your wishes are?”
“Are there any family you want to discuss this with?”
Patient has Capacity
“I respect your decision even if I don’t agree with it, and I feel you have capacity to make this choice.”
“Do you think we could think about an alternative plan?”
- Safety net
- Discharge and close
Patient lacks Capacity
- Explain why, and that you need to act in the patient’s best interests.
- Offer written information.
- It is good practice if able to offer a second opinion.
Irrespective of the outcome of your assessment it is imperative that you have documented thoroughly your interaction with the patient. and the assessment of their capacity.
Mental Health Act
Mental Health Act Assessment
Background
The Mental Health Act (1983) is legislation that helps to ensure appropriate assessment (mental health act assessment) and treatment of those with mental health disorders whilst also trying to uphold their rights.
Criteria for use
- Suffering from a mental disorder
- Needs emergency admission to protect health/safety of the patient or others
Requirements for use
- Detention for treatment of the mental disorder alone
- In the patient’s best interests
- All voluntary methods have failed
Sections of the Act
| Section 2 | For assessment Up to 28 days |
| Section 3 | For treatment of a mental health illness Up to 6 months |
| Section 4 | For assessment for emergency treatment Less than 72 hours |
| Section 5(2) | Doctors‘ holding power – to allow mental health act assessment Up to 72 hours |
| Section 5(4) | Nurses‘ holding power (until decision regarding 5(2) can be made) Up to 6 hours |
| Section 135 | Police power with a warrant to enter a person’s home and remove them to a place of safety Up to 24 hours |
| Section 136 | Police power which allows police to detain a person who is in public and felt to be mentally disordered and causing disturbance, to a place of safety Up to 24 hours |
Substance misuse
Alcohol History and Education
Alcohol and substance misuse is unfortunately a common presentation to Emergency Departments and as such is easily a fairly realistic presentation to have as an OSCE station.
There are a number of ways such a station could be devised. Examples include:
- Management of the acutely intoxicated patient (i.e. conflict resolution)
- The intoxicated patient wishing to leave (i.e. capacity assessment)
- Agitated delirium (i.e. principles of rapid tranquilisation)
- Making every encounter count (MEEC) conversation
The approach below focuses on a MEEC encounter as both conflict resolution and capacity have already been covered. It is based on a scenario where someone has highlighted to you their concerns about a patient and you have been asked to assess them. Recreational drugs use could easily be substituted for alcohol.
Introduction
“Hello. My name is Phil. I am one of the medical students.”
“Before we start can you confirm your name and date of birth for me please?”
“Are you comfortable? Do you need any pain relief or anything to eat and drink?”
“The nursing staff have asked me to come and see you because they are concerned you are a little shaky and sweaty? What do you think of that?”
Background
“Before we explore why you are here today can I just find out a little bit more about you please?”
- Past medical history: medical; surgical; obgyn; psychiatric.
- Allergies
- Regular medications (including contraception and over the counter)
- Family history
- Social
- Smoking,
- Drinking,
- Recreational drugs,
- Employment,
- Foreign travel,
- Who do you live with?
- Children at home (any Social Services involvement?),
- Safe at home (HITS – Hurts, Insults, Threats, Shouts)?
Alcohol focus
“From what you mentioned a moment ago it sounds like you drink alcohol fairly regularly. Would it be ok if I asked you some more questions about that please?”
CAGE questionnaire
- Have you ever felt the need to Cut down your drinking?
- Have people Annoyed you by criticising your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
“How much do you drink each day on average?”
“What do you drink?”
“What happens if you don’t drink?”
“Have you ever had a seizure because of stopping drinking suddenly?”
Probing and Plan
Some of the themes around alcohol consumption you may wish to explore:
“What do you think about the amount you drink, do you think it might be too much?”
“Have you an idea of what the recommended units per week are?”
“Do you think alcohol might have played a part in you hurting yourself today?”
“Have you ever thought about talking to someone about trying to reduce how much you drink?”
“Would you like for me to ask someone to come and see you while you are here?”
Close
“Thank you for being so honest with me.”
“I will ask someone to come and see you today while you are with us.”
“In the meantime would it be ok if I gave you some vitamins through your drip and would you like me to prescribe you some medication to make you feel less shaky and on edge?”
“Ok, I will do that, do you have any final questions before I go?”
Example scenarios
- Safeguarding/abuse: Paediatric non accidental injury; elder abuse, FGM; domestic violence
- Mental health: Postpartum depression; acute psychosis; severe eating disorders; delirium
- Alcohol/substance misuse: Aggressive and disturbed behaviour
Additonal Resources
Alcohol/substance misuse