Psychscene Q&A quiz.docx

**Ethical issues in report writing - Civil** John has been reluctantly seeing you monthly. He tells you that the work environment has become unbearable. After an incident at work, which involved an altercation with students, John has taken time off due to sickness. 5 months later you receive a lett...

**Ethical issues in report writing - Civil** John has been reluctantly seeing you monthly. He tells you that the work environment has become unbearable. After an incident at work, which involved an altercation with students, John has taken time off due to sickness. 5 months later you receive a letter from WorkCover outlining that they need a report from you regarding John. They have also sent a request for his notes.  **List the key points in your approach to this request** 1. **Dual agency dilemma / Conflict of interest** : I will clarify my role. Are you providing a report as a treating doctor or as an independent psychiatrist. (As an independent psychiatrist you will be assisting court whilst as a treating psychiatrist you will act in the best interest of the patient) 2. **Privacy and Confidentiality:** The doctor patient relationship is confidential except in certain circumstances where disclosure is required by law such as harm to children, harm to third party or harm to self. In this case, I will seek advice from my medico-legal insurance as to my obligations in providing the notes. 3\.  **Autonomy and informed consent:** I will also speak to the patient and inform him of the request. I will obtain informed consent from the patient after explaining the process and explaining my role.  4. **Beneficience:** If I were to provide a report will I be acting in the best interest of my patient?  5. **Non-Maleficence:** If I write a report or provide notes, will my patient come to harm?  **Management of Patient suicide** **John\'s mental state deteriorates over the next few months. You admit him to a private hospital. 6 days into the admission you receive a phone call from the ward stating that John has committed suicide. ** **Outline how you would proceed** 1. **Attend ward and gather information:** How, when, who witnessed it. Have police been informed?  Has the clinical director and NUM been informed?  2. **Advise staff to isolate the body** and not disturb the scene until police arrive.  3. **Inform** clinical director and NUM personally 4. **Document** last mental state, ask staff to ensure adequate documentation. Photocopy notes and keep one copy as it will be required for the coroner 5. **Inform family:** This is best done after discussing it with staff and director as to the best way to inform family. A face to face meeting with a staff member that the family knew would be appropriate. Respect family wishes.  6. **Offer the family opportunity to ask questions**, vent anger and hostility. If family wishes to complain, explain avenues to do this i.e complaints pathway.  7. **Inform family of supports** available and identify any vulnerable individuals in the family that may need additional support 8. **Staff debriefing** 9. **Patient debriefing** to avoid rumours spreading and to maintain trust in the therapeutic relationship.  10. **Contact medicolegal insurance** and inform them 11. **Coroner\'s report** preparation will be necessary once a request if obtained 12. **Psychological autopsy** / Root Cause Analysis (RCA) 13.** Self reflection: **speak to colleagues and obtain advice 14. **Case conference** to learn from incident **Debt and Mental Illness- Principles** 1. **Clarify role:** Your role is not to provide financial advise but to refer patients to appropriate individuals and liaise with organisations to assist the patient 2\. Advise patient not to ignore the problem 3\. Identify priority debts and advise patient to contact and inform respective organisations e.g banks, utility companies 3\. Is the client thinking of borrowing more money?  4\. Is there a mental illness that may be impacting on financial stability? e.g. mania, gambling, substance use disorder 5\. Involve social worker 6\. Maximise client government benefits 7\. Refer to a debt advisor or financial advisor 8\. Refer to legal aid if legal issues present.  9\. Support letters can be sent to bodies advocating for flexibility e.g interest only payments on mortgage etc.  10\. Involve consumer consultant **Young Male with Schizophrenia- Assessment of Risk** **Stan is a 20 year old indigenous male. He has been admitted to the mental health unit after a violent assault on his father. His parents report that he has not been himself over the last 6 months and has been seeing talking to himself on a number of occasions. He is also reported to smoke cannabis on a regular basis. ** **List the short and long term risk factors you would assess for in this case that would increase the risk of violence?** This question can be answered by using the HCR-20 in the diagram.  Additionally one must add the cultural aspects that play a role.  1\. Holistic model of health 2\. Distrust of \'Western mental health practices\'  3\. Lack of availability of indigenous mental health liaison workers 4\. Geographical isolation and poor follow up 5\. Negative family attitudes to medication and societal stigma 6\. Specific issues related to non-compliance as outlined in notes.  **Young Male with Schizophrenia- Assessment of Risk** **Stan is a 20 year old indigenous male. He has been admitted to the mental health unit after a violent assault on his father. His parents report that he has not been himself over the last 6 months and has been seeing talking to himself on a number of occasions. He is also reported to smoke cannabis on a regular basis. ** **List the short and long term risk factors you would assess for in this case that would increase the risk of violence?** This question can be answered by using the HCR-20 in the diagram.  Additionally one must add the cultural aspects that play a role.  1\. Holistic model of health 2\. Distrust of \'Western mental health practices\'  3\. Lack of availability of indigenous mental health liaison workers 4\. Geographical isolation and poor follow up 5\. Negative family attitudes to medication and societal stigma 6\. Specific issues related to non-compliance as outlined in notes.  **Young Male with Schizophrenia- Assessment of Risk** **Stan is a 20 year old indigenous male. He has been admitted to the mental health unit after a violent assault on his father. His parents report that he has not been himself over the last 6 months and has been seeing talking to himself on a number of occasions. He is also reported to smoke cannabis on a regular basis. ** **List the short and long term risk factors you would assess for in this case that would increase the risk of violence?** This question can be answered by using the HCR-20 in the diagram.  Additionally one must add the cultural aspects that play a role.  1\. Holistic model of health 2\. Distrust of \'Western mental health practices\'  3\. Lack of availability of indigenous mental health liaison workers 4\. Geographical isolation and poor follow up 5\. Negative family attitudes to medication and societal stigma 6\. Specific issues related to non-compliance as outlined in notes.  **Young Male with Schizophrenia- Assessment of Risk** A screenshot of a document Description automatically generated **Stan is a 20 year old indigenous male. He has been admitted to the mental health unit after a violent assault on his father. His parents report that he has not been himself over the last 6 months and has been seeing talking to himself on a number of occasions. He is also reported to smoke cannabis on a regular basis. ** **List the short and long term risk factors you would assess for in this case that would increase the risk of violence?** This question can be answered by using the HCR-20 in the diagram.  Additionally one must add the cultural aspects that play a role.  1\. Holistic model of health 2\. Distrust of \'Western mental health practices\'  3\. Lack of availability of indigenous mental health liaison workers 4\. Geographical isolation and poor follow up 5\. Negative family attitudes to medication and societal stigma 6\. Specific issues related to non-compliance as outlined in notes.  **oung Indigenous Male with Schizophrenia-Ongoing Symptoms** **Following your assessment of Stan an indigenous male, you diagnose him with schizophrenia. His medical investigations are normal. You find out that he has been admitted previously to another mental health unit where he was diagnosed with schizophrenia. He was started on Risperidone 6 mg, which he stopped 9 months ago. He continues to complain of ongoing auditory hallucinations but refuses to take any medication.** ** Outline your approach to this situation.** **List the factors affecting compliance in this case?** **Outline how you would specifically address his resistant hallucinations after finding out he was compliant with medication.** ** 1. Attempt to establish therapeutic alliance and assess for factors affecting insight and compliance** **a. Personal factors ** - Cultural aspects (holistic understanding of health, alternate explanatory models of illness) - negative attitudes to medication - Stigma - Familial negative attitudes ot mental illness b\. Medication factors - Side effects of medication: EPSE\'s (AIMS examination), High prolactin levels and sexual side effects, gynaecomastia, weight gain, sedation and slowing down - Difficulty remembering to take medication - Ineffectiveness of medication c\. Illness factors:  - Delusions and hallucinations regarding treatment - Personality factors with lack of trust - Cognitive impairment  - Substance use  d\. System factors:  - Lack of cultural sensitivity - Absence of culturally trained workers and absence of indigenous mental health liaison workers - Distance to travel to see team  - Cost Treatment of resistant hallucinations 1\. Provide psychoeducation to patient about treatment options and attempt to engage him 2\. Rule out organicity: MRI scan , TFT\'s  3\. Rule out substance use 4\. Switch antipsychotics to alternate one like Olanzapine or Asenapine 5\. If non-compliance is an issue consider depot preparations. Issues such as consent and legal framework are to be considered. e.g CTO 6\. If no response , discuss possibility of clozapine with patient and family with risks explained. Care to be taken in view of ethnic profile as higher risk of metabolic issues.  7\.  CBT and hearing voices group taking into account cultural aspects or one on one therapy tailored to patient incorporating cultural aspects and nature of voices. A particularly skilled therapist will be required to achieve this. involve the indigenous liaison worker.  8\. Augmentation strategies like mood stabiliser augmentation with antipsychotic 9\. Music and headphones for distraction 10\. Anxiety reduction strategies 11\. TMS has some evidence but is not routine.  Stigma and Mental Health - Community Management =============================================== **After a 4 week admission Stan is better. The family is concerned about his being discharged in the community as it is an indigenous community and his parents are worried about the impact of this on Stan's mental health. They do not want any community follow up from the CMHT, but want to go to the traditional healer.** ** How would you manage this situation?** 1\. Arrange a meeting with parents and Stan: Involve a indigenous liaison worker if possible.  2\. Clarify specific concerns of the family: What do they feel will happen? How do they feel we can help? What do they think they would like?   3\. Provide psycho-education about schizophrenia and its treatment options. Attempt to establish therapeutic alliance by taking into account cultural issues 4\. Explain that traditional healing systems and western models can co-exist side by side: We can work together with the traditional healer in a liaison model 5\. Consider a meeting with community elders after obtaining consent from family and Stan.  6\. Reassurance provided in a realistic manner about role of mental health services: explain the nature of the team and community follow up. Also explain that if risk issues are present such as risk of harm to self or others legal aspects may be needed such as CTO or inpatient admission to protect Stan. At all points explain to the family that you will be acting in the best interest of Stan and Family.  7\. If media is involved than involve the service media liaison officer 8\. Wider issues such as community education, combating stigma, employment for Stan.  **Motivational Interviewing Principles**  **You have an obese patient with depression and diabetes.  The endocrinologist has reported that your patient has to lose weight to prevent the onset of Insulin Dependant Diabetes Mellitus. During the interview when you bring up the topic of losing weight, She says, " I don't need to follow my diet as long as I'm feeling OK."** **Outline your approach to the situation to assist the patient in losing weight.** ***(Please note that the same principles are applicable for Alcohol and the example used here is for alcohol dependence). *** **Interviewing Principles (OARS)** **1. Assess for stage of change** **2. Ask Open-ended questions** - I understand you have some concerns about your drinking (losing weight). Can you tell me about them? **3**.** Make Affirmations** - The patient's strengths and efforts for change are noticed and affirmed - I appreciate that it took a lot of courage for you to discuss your drinking (weight) with me today - You appear to have a lot of resourcefulness to have coped with these difficulties for the past few years - Thank you for hanging in there with me. I appreciate this is not easy for you to hear **4. Use Reflections to enhance cognitive dissonance** - Involves rephrasing a statement to capture the implicit meaning and feeling of a patient's statement - Encourages continual personal exploration and helps people understand their motivations more fully - You enjoy the effects of alcohol in terms of how it helps you unwind after a stressful day at work and helps you interact with friends without being too self-conscious. But you are beginning to worry about the impact drinking is having on your health. In fact, until recently you weren't too worried about how much you drank because you thought you had it under control. Then you found out your health has been affected and your partner said a few things that have made you doubt that alcohol is helping you at all - I understand that you feel OK and have not considered losing weight. I acknowledge that it is a difficult topic for you to discuss but I want to touch on the impact of your weight on your health. Is that OK? (Since patient is at precontemplation). - What are the advantages of not losing weight? What are the disadvantages? **5. Use Summarising** - Links discussions and 'checks in' with the patient - If it is okay with you, just let me check that I understand everything that we've been discussing so far. You have been worrying about how much you've been drinking in recent months because you recognise that you have experienced some health issues associated with your alcohol intake, and you've had some feedback from your partner that she isn't happy with how much you're drinking. But the few times you've tried to stop drinking have not been easy, and you are worried that you can't stop. How am I doing? **4 further principles ** 1\. Express Empathy 2\. Roll with resistance 3\. Enhance self efficacy 4\. Develop discrepancy or enhance cognitive dissonance Tacking Non-adherence due to Forgetfulness ========================================== **A 52-year-old female who takes 2 antidepressants, 2 mood stabilisers and 2 antipsychotics along with metformin and anti-hypertensive reports that she finding it difficult to remember to take her medication. ** ** List the strategies to assist her** 1\. Dosette box 2\. Alarm clock, Mobile phone alarms 3\. Post it\'s  4\. Simplify regime e.g. all morning or note if possible 5\. Involve family member in administration of medication 6\. If lack of insight- adherence therapy incorporating motivational interviewing techniques 7\. Depot medication 8\. Rule out cognitive dysfunction and treat cause if possible  **Eating Disorders- Risk factors** **A 21 year old female has been recently diagnosed with an eating disorder. ** **List the factors you would focus on in developing your formulation** - Female gender - Being from the developed world where the 'thin ideal' prevails. - Migrants from the developing world - Those living in urban areas and undertaking life pursuits where body image concerns predominate, for example, competitive gymnastics and fashion modelling. - Genetic predisposition - Early menarche - Epigenetic changes to DNA structure: food deprivation, severe trauma - Family history of eating disorders - Early attachment and developmental difficulties - Premorbid obesity - Interpersonal problems - Dieting or other causes of rapid weight loss (Mitchison and Hay, 2014; Stice, 2002). - Rapid weight loss from any cause, including physical illness, can trigger cognitive changes **Psychological factors** - A 'milieu' of weight concern in formative developmental years - Low self-esteem (all eating disorders) - High levels of clinical perfectionism for those with anorexia nervosa - Impulsivity for bulimic disorders. - Emotional and sexual child abuse increases personal vulnerability, most likely through impeding a robust sense of self-worth and adaptive coping. The eating disorder then provides a sense of improved self-esteem and self-control for the individual (Stice, 2002). - Obsessive thinking about food, in turn precipitating and perpetuating the symptoms of anorexia nervosa (Keys et al., 1950). - Positive reinforcement as maintaining factor e.g sense of achievement, societal reinforcement - Jane is a 16-year-old female referred by her GP. She lives with her parents and younger sister. She presented to the GP with nausea and vomiting. Her medical investigations revealed a low potassium. The GP feels that she may have an eating disorder. - ** List the salient features in history, examination and formulation you would focus on to make a diagnosis** - **1. History Taking:** Symptoms of anorexia nervosa which include but are not limited to: dietary restriction; weight loss; inability to restore weight; body image disturbance; fears about weight gain; binging; purging; excessive exercise; early satiety; constipation; and the use of laxatives, diuretics, or medications to lose or maintain low weight (APA, 2013). Symptoms of bulimia include preoccupation with food and compensatory behaviours after binges.  - **2. Disturbed eating behaviours, **e.g. eating apart from others and ritualistic patterns of eating such as prolonged meal times and division of food into very small pieces (Wilson et al., 1985). - **3. Accurately assess nutritional and fluid intake: **Specific enquiries made as to the adequacy of main meals and snacks consumed. - **4. Collateral:** Collateral sources such as family members and other clinicians involved in the person's care should be utilised. - **5.** **A brief physical examination i**ncluding measurement of weight, height, calculation of BMI, seated and standing pulse rate to detect resting bradycardia and/or tachycardia on minimal exertion due to cardiac deconditioning, blood pressure (seated and standing) and temperature. These findings are needed to determine if immediate hospital admission is required. The assessment should also include any history of fainting, light-headedness, palpitations, chest pain, shortness of breath, ankle swelling, weakness, tiredness and amenorrhoea or irregular menses. Check nails, swollen glands, dental caries etc.  - **6. Investigations:** Serum biochemistry to detect hypokalaemia, metabolic alkalosis or acidosis, hypoglycaemia, hypophosphataemia, and hypomagnesaemia, serum liver function tests, serum prealbumin levels and a full blood examination looking for evidence of starvation-induced bone marrow suppression such as neutropaenia and an electrocardiogram (ECG). A bone mineral density scan should be performed routinely if the person has been underweight for six months or longer with or without amenorrhea and thereafter every two years whilst still struggling with an eating disorder (Mehler et al., 2011). - **7. Assessing psychiatric comorbidity: **e.g. anxiety, depression, substance misuse, suicidality, personality disorders, anxiety disorders and deliberate self-harm. However, clinicians should be aware that depression, obsessional thinking, anxiety and other psychiatric symptoms can represent the reversible effects of starvation on the brain (Keys et al., 1950). - **8. Cognitive Assessment:** Assessing cognitive changes due to starvation such as slowed thought processing, impaired short-term memory, reduced cognitive flexibility and concentration and attention difficulties (Hatch et al., 2010). - **9. Possible predisposing and precipitating factors: **see risk factors in previous question - Anorexia Nervosa - Challenging Management ========================================= Following your assessment you make a diagnosis of Anorexia Nervosa. She has a BMI of 14. On the paediatric ward where she has been admitted, she refuses to eat and threatens to kill herself if given food. The nursing staff has become hostile against the patient. They ask you to have her transferred to the psychiatric ward. ** Outline your immediate management plan?** 1. **Ethical issue** : Duty of care vs. Autonomy of patient. Since she is 16 she would have a guardian. Find out who are legal guardians.  2. **Arrange meeting with nursing staff with CL nurse:** Acknowledge the difficulty in management and provide positive affirmation. Inform that team will be available to support them  3. **Inform paediatric team about the seriousness of the issue**. BMI of 14 may indicate serious medical risks and a thorough medical evaluation and treatment to avoid refeeding syndrome is required and this is best provided on the medical ward as regular monitoring of vitals is required. 4\. Provide psycho-education about Anorexia nervosa, personality factors and psychodynamic mechanisms resulting in anger or refusal of food. (projection, acting out, splitting, anger turned inwards etc.) 5\. Arrange a nurse special either a medical nurse special or psychiatric nurse special.  6\. Provide ongoing psychiatric liaison 7\. Inform guardian respecting confidentiality as maintaining confidentiality may be required to build trust and establish therapeutic alliance 8\. Involve the specialist eating disorder service 9\. If she refuses to eat with significant medical risks, speak to guardians, clinical director/ emergency guardianship tribunal to obtain advice about treatment and use of mental health act. This may differ from state to state and country to country..  Anorexia Nervosa-Psychoeducation to Family ========================================== She continues to remain on the paediatric ward. Her behaviour has settled. Her parents come to meet you to discuss management of their daughter's condition. They feel that they are to blame for her condition. **Outline the key points you would cover in the discussion?** 1. **Establish therapeutic alliance:** Explain the Anorexia Nervosa is an illness and that they are not to blame for this. Provide praise, encouragement and positive reinforcement as they will be important part of treatment. There is no research evidence that proves a link between family dysfunction and the onset of anorexia nervosa, although research supports improved outcomes in anorexia nervosa when families are involved in treatment. **2. Provide opportunity to ask questions first** **3. Explain that anorexia is a eating disorder:** Anorexia nervosa occurs in about 0.5% of girls and young women in developed societies. 9 out of 10 individuals affected are females.  4. **Explain the seriousness of the illness but at the same time explain that it is treatable. ** It can lead to severe weight loss, chronic physical disabilities such as osteoporosis (bone loss with weakened bone structure and increased risk of fractures), growth retardation, infertility, impaired thinking and concentration, bowel and intestinal disorders and major disruptions to emotional, social and educational development. It can be life threatening. People can fully recover from anorexia nervosa. Research says that if anorexia nervosa is treated early in its course, particularly in children and adolescents, then recovery occurs more quickly and more often than if treatment is delayed 5. **Weight restoration is an essential first step in recovery** but not a sign of recovery. It takes time to heal the mind from anorexia nervosa and restore a sufferer to a state where they are not dominated by negative feelings related to weight and food. 6\. Explain that management will be as part of a **multidisciplinary team** with a psychologist, nurse, psychiatrist, dietician and family therapy 7. **Psychological therapies:** Inform that families play an important role in management and research shows that family therapy e.g Maudsley Family therapy ) is evidence based for the treatment of anorexia nervosa.  (See components of family therapy in the next section) 8. **Medication:** Medication may be required if the obsessive thoughts are severe or if there is anxiety and depression. SSRI\'s (antidepressants) and antipsychotics such as olanzapine are indicated.  9\. Provide information about support groups  Principles of Family Based Treatment in Anorexia Nervosa ======================================================== 1\. Adolescent is embedded in the family and the involvement of the family is a key component of success.  **Phase 1 : Weight restoration:** Therapist has a direct observation of the family\'s interaction patterns during eating. Therapist directs discussion (enhance circular communication) to reinforce a strong alliance between parents at promoting weight restoration in their child.  **Phase 2: Transitioning control of eating back to the adolescent ** **Phase 3 :** **Adolescent issues and termination:** After medical issues are addressed and patient has regained a normal weight. Enhancing separation individuation, addressing conflict, enhancing self efficacy.  Other principles such as addressing high emotional expression, psychoeducation, allow family to vent anger and hostility, take feeling of blame away from parents remains.  **Refeeding Syndrome-Principles in Management** Refeeding syndrome can occur in Anorexia nervosa, chronic alcoholsim, oncology patients, sever depression and anyone with severe weight loss.  Assessment  - Dietician assessment - Assess weight change, nutrition, alcohol intake and psychosocial issues - Investigations: PO4, Mg, NA and K - Glucose Correct deficiencies with close monitoring with admission to a medical ward.  Slow replenishment **Refeeding Syndrome (RANZCP Guidelines, 2014)** - Refeeding syndrome is understood to be due to the switch from fasting gluconeogenesis to carbohydrate-induced insulin release triggering rapid intracellular uptake of potassium, phosphate and magnesium into cells to metabolise carbohydrates (Kohn et al., 2011). - The low body stores of such electrolytes due to starvation, can lead to rapid onset of hypophosphataemia, hypomagnesia and hypokalaemia. In addition, insulin-triggered rebound hypoglycaemia can occur, exacerbated by the fact that such patients have depleted glycogen stores. - Risk of refeeding syndrome can be reduced by 'starting low' and 'going slow' with nutrition, and monitoring serum phosphate, potassium and magnesium daily for the first 1--2 weeks of refeeding, and replacing these electrolytes immediately if they fall below normal range - The CPG group recommends taking a 'middle path' with adults, commencing refeeding at 6000kJ/day. This should be increased by 2000kJ/day every 2--3 days until an adequate intake to meet the person's needs for weight restoration is reached. - This diet should be supplemented by phosphate at 500mg twice daily and thiamine at least 100mg daily for the first week, and thereafter as clinically indicated for people at high risk of refeeding syndrome (e.g. BMI \