Archive for the ‘Educational material’ Category

Models of mental illness

Thursday, November 3rd, 2011

(Picture credit – taken with a tilt shift lens – looks like a model…)

It’s widely accepted that individuals can be disturbed or troubled of mind.  What is controversial is how we should understand this. 

Asides psychiatrists, many professional disciplines work and research in the field of mental disorder.  Each discipline approaches the subject from their own viewpoint, using their own conceptual model to explain what they find before them. 

Alas there is no single model that has complete explanatory power.  To fully understand an individual’s difficulties it is often necessary to borrow from several.  This would be the favoured approach from an eclectic practitioner.  In practice it’s easy to favour a pet model which most closely fits one’s world view and defend this against those supported by others. 

The on-going debate about the merits of drug treatments versus talking therapy can be viewed as a clash of models: biological versus psychodynamic/cognitive.

The disease or biological model

This model holds that any dysfunction that effects mental functioning can be regarded as ‘disease’ in a similar way to dysfunction that affects other parts of the body.

In the disease model, a disorder affecting mental functioning is assumed to be a consequence of physical and chemical changes which take place primarily in the brain.  Just like any other disease a mental disease can be recognised by specific and consistent signs, symptoms and test results.  These distinguish it from other diseases. 

Psychiatrists who adhere to the disease model are often referred to as ‘biological psychiatrists’ (as in ‘he’s very biological’).
With a biological approach comes a preference for physical treatment methods, primarily drugs, but also ECT. 

This model best applies to schizophrenia

The psychodynamic model

The central tenet of the psychodynamic model is that a patient’s feelings have lead to problematic thinking and behaviour.  These feelings may be unknown to the patient and have formed during critical times in their life, due to interpersonal relationships. 

These unknown (or unconscious) feelings are uncovered during therapy.  Therapy can take place over a large number of sessions and over a time period of a year and beyond. 

During therapy a relationship builds up between therapist and patient.  The emotions that the patient attaches to the therapist are collectively known as ‘transference’, and those the therapist attaches to the patient collectively as ‘counter transference’.  By understanding these feelings a patient may gain an understanding that they can take with them to future relationships. 
This model is applied broadly, but has limited applicability to the most severe mental disorders. 

The behavioural model

The behavioural model understands mental dysfunction in terms theory emerging from experimental psychology.

Symptoms, as understood by the behavioural model, are a patient’s behaviour.  This behaviour has come about by a process of learning, or conditioning.  Most learning is useful as it helps us to adapt to our environment, for example by learning new skills.  However some learning is maladaptive and behaviour therapy aims to reverse this learning (counter conditioning). 

This model best applies to phobias.

The cognitive model

The cognitive model understands mental disorder as being a result of errors or biases in thinking.  Our view of the world is determined by our thinking, and dysfunctional thinking can lead to mental disorder.  Therefore to correct mental disorder, what is necessary is a change in thinking. 

This model will be familiar to anyone who has trained or undergone cognitive behavioural therapy (CBT).  CBT aims to identify and correct ‘errors’ in thinking.  In this way, unlike psychodynamic therapy, it takes little interest in a patient’s past. 
This model is widely used, but classically applies to depression and anxiety.

The social model.

The social model regards social forces as the most important determinants of mental disorder.  The social model takes a broader view of psychiatric disorder than any other model.  It regards a patient’s environment and their behaviour as being intrinsically linked. 

In some ways it is like the psychodynamic model, which also sees patients as moulded by external events.  However whereas the psychodynamic model sees mental disorder as highly personalized and its determinants not immediately recognizable, the social model sees mental disorder as based on general theories of groups and caused by observable environmental factors. 

Example

For someone who develops persistent depression following the death of a close relative :

“This can be perceived in several ways by psychiatrists.  One sees the depression as a pathological event that is directly due to the biochemical changes occurring in the brain of someone who is predisposed to pathological depression through an accident of illness.  Another sees the depression as a reactivation of unresolved childhood conflicts over an early loss.  Another regards the depression as part of the normal mourning process that has got out of control because the person’s thoughts become fixed in a negative set which sees everything in the most pessimistic light.  Yet others conclude that the mourning response has been exaggerated primarily by society or see it as an abnormal form of learning which is no longer appropriate for the situation but is receiving encouragement from some quarter (positive reinforcement)”

From Models for mental disorder

MPS Casebook: A dosing disaster

Thursday, May 19th, 2011

I have a new case report published in Casebook, which is published by the Medical Protection Society

 

A dosing disaster

Mrs E, a 29-year-old solicitor, who was 35 weeks pregnant, was admitted to hospital for antihypertensive treatment as she had developed pre-eclampsia. She had a history of epilepsy, which was well controlled by treatment with phenytoin and phenobarbitone. She had been prescribed these medications since her teenage years and had decided to continue with them throughout her pregnancy after appropriate advice and counselling.

Dr T made a diagnosis of puerperal psychosis; no differential diagnosis was recorded and the possibility of drug toxicity was not considered. Sedation was initially prescribed, but during the next 24 hours Mrs E’s symptoms failed to improve

On admission to the obstetric ward Mrs E was clerked in by Dr F, a junior doctor who was on-call and had no prior experience with phenytoin prescribing. As Dr F was completing a drug chart for Mrs E, she was distracted by an urgent telephone call and on her return she incorrectly charted Mrs E’s phenytoin at three times the appropriate dose.

Two days after admission, Mrs E entered into spontaneous uncomplicated labour and delivered a healthy baby boy. However, six hours later she began to exhibit symptoms suggestive that she was developing a psychiatric disorder. Initially she was distractible and expressed paranoid ideation about other patients on the ward; she soon became psychotic, reporting auditory hallucinations of voices discussing her actions.

Mrs E was assessed by psychiatry specialist trainee Dr T. Dr T did not look at Mrs E’s drug chart and only reviewed her medical notes. These detailed her medication, but did not supply dosing information. Following his assessment Dr T made a diagnosis of puerperal psychosis; no differential diagnosis was recorded and the possibility of drug toxicity was not considered.

Sedation was initially prescribed, but during the next 24 hours Mrs E’s symptoms failed to improve and she became more agitated. As a result, an antipsychotic medication was started. Over the next 12 days and despite increasingly high doses, Mrs E failed to respond to antipsychotic medication and her psychotic symptoms continued. It was noted that she appeared to be increasingly confused, had slurred speech and was observed to have an abnormal gait.

A referral was made for a neurological opinion to exclude an organic brain syndrome. On reviewing Mrs E’s drug chart, the on-call neurologist noticed the medication error and on examination of Mrs E he was also able to identify other symptoms of phenytoin toxicity. Phenytoin administration was immediately stopped and once Mrs E’s toxic levels had subsided her psychotic symptoms resolved.

No long-term damage was caused to Mrs E’s health, but she made a complaint against the hospital.

Learning points:

Something as apparently simple as incorrectly charting a patient’s regular medication can have serious consequences. This task is regularly undertaken by junior doctors who may not be familiar with certain medications.

Because the psychosis emerged in the post-partum period, it was assumed that puerperal psychosis was the correct diagnosis. It is important to keep in mind other possible causes for Mrs E’s presentation.

When a patient does not respond to treatment as expected, it is always wise to re-examine their history and double check even the most obvious but unlikely explanations for their condition.

Normally drug charts are checked by a pharmacist, but it is unclear whether this happened on this occasion. Every hospital should have a procedure where a pharmacist checks a patient’s medication, but this is sometimes overlooked. Regardless of any protocol, the prescriber has the ultimate responsibility for anything they chart.

A large number of medications can cause psychiatric difficulties under circumstances of use, abuse or withdrawal.

Too close to home

Saturday, September 11th, 2010

I wrote this cautionary tale (from supplied details) as a hired gun for MPS Casebook September 2010 – one of my favourite professional publications. 

Ms N, a 32-year-old psychiatric nurse specialist, had been off work for several weeks following an argument with another member of her team. She self-referred to see Dr B, a psychiatrist, with whom she worked closely within the same multidisciplinary team.

She explained to Dr B that her alcohol intake had recently increased and she had become unusually restless with a reduced need for sleep. She had also been spending more money than usual and had been getting into fights with her partner and sometimes with strangers.

At the consultation she said that in the past she had experienced similar episodes of increased activity and also reported periods of low mood. She had described herself as “moody”, but had never considered this sufficiently serious to seek referral to a psychiatrist. Dr B made a diagnosis of bipolar disorder currently hypomanic. Ms N agreed to start pharmacological treatment.

Ms N and Dr B had a long conversation about the treatment of bipolar disorder, and Ms N was prescribed sodium valproate, a mood stabilizer.

At the next consultation her sleep was improving and her hypomania appeared to be reducing. However she soon started to complain of low mood and Dr B decided to prescribe lamotrigine, in addition to her valproate, as a treatment for bipolar depression. Ms N was familiar with both sodium valporate and lamotrigine as treatments for bipolar disorder and was taking precautions to avoid pregnancy as valproate is a known teratogen.

The symptoms of Ms N’s depression persisted and she had still not returned to work. As a result, Dr B suggested that they should increase the dose of lamotrigine. Ms N was concerned about the impact a history of psychiatric disorder would have on her employment, so she sought to put pressure on Dr B to limit what was documented in her records.

Unfortunately, as a result of the increase in the dose of lamotrigine, Ms N developed a severe form of Stevens-Johnson syndrome and spent some time seriously ill in ICU.

The conversation about the increase of lamotrigine dose, and any discussion of serious untoward possible side effects, was poorly recorded. It is unclear whether the possibility of developing Stevens-Johnson syndrome was touched upon; Dr B had some recollection of the exchange but had not committed this to writing. She remembered thinking that she didn’t want to sound patronising to Ms N, as she thought Ms N was usually extremely competent at her nursing job.

Following her time in ICU, Ms N was unable to return to work and she made a claim against Dr B. Experts who examined the case were critical of Dr B’s management of Ms N’s drug regime, as there is a known high risk of developing Stevens-Johnson syndrome when sodium valproate and lamotrigine are combined – a risk that increases with dose. The claim was settled for a high sum.

Learning points

  • It is good practice not to treat people too close to you, either relatives or colleagues.
  • Patients should receive assurance about confidentiality and, if they are unsatisfied, alternative arrangements can be made. The best patient care is normally achieved through multi-disciplinary teamworking and appropriate sharing of information between professionals.
  • Good record-keeping is essential in all medical specialties. Documenting relevant conversations is always good practice and can make a difference at the time of defending a case.
  • Taking knowledge for granted with any patient poses potential risks and, when ill, even the most expert person becomes vulnerable. It is safer to assume no prior understanding, even with patients whom one might expect to be well-informed.
  • Many medications have effects, especially when used in combination. Patients need to be fully informed of possible side effects and adequately supervised.
  • There is a known risk when combining sodium valproate and lamotrigine (see relevant prescribing guidance).

 

The Rosenhan experiment examined

Wednesday, September 1st, 2010

The ‘Rosenhan experiment’ is a well known experiment examining the validity of psychiatric diagnosis.  It was published in 1975 by David Rosenhan in a paper entitled ‘On being sane in insane places’

The study consisted of two parts.  The first involved ‘pseudopatients’ – people who had never had symptoms of serious mental disorder – who, as part of the study, briefly reported auditory hallucinations in order to gain admission to psychiatric hospitals across the United States. 

After admission, the pseudopatients no longer reported hallucinations and behaved as they ‘normally’ would.  Despite this many were confined as inpatients for substantial periods of time and all were discharged with the diagnosis of a psychiatric disorder. 

For the second part of the experiment staff at a teaching hospital, whose staff had learned of Rosenhan’s above results, were informed that one or more pseudopatients would attempt to be admitted to their hospital over an ensuing three month period.  Many patients were subsequently identified as likely pseudopatients but in fact no pseudopatient had been sent. 

‘On being sane…’ also examines, though the experience of the pseudopatients, the patient experience of psychiatric inpatient wards.  This part of the paper is discussed often only in passing.

Rosenhan’s conclusion was stark:  A psychiatric diagnosis is more a function of the situation in which the observer finds a patient and reveals little about a patient themselves. 

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals“

Despite being over thirty years old the Rosenhan experiment remains well known and is often cited.  Accounts of the experiment are widespread on the internet, but critiques are rarer and many people accept the study’s conclusions at face value. 

This was an audacious experiment and the subsequent paper had an extremely good title, but was Rosenhan justified in his conclusion?  Anthony Clare, amongst others, wrote that Rosenhan was ‘theorising in the absence of sufficient data’.  But if Rosenhan was correct then his experiment remains extremely important; as if diagnoses are in ‘the mind of the observer’ and do not reflect a quality inherent a patient, they are of little use. 

If you wish to read the original paper it can be found here.  Spitzer’s 1975 critique is available here (for a fee).  Davis’s critique here.  Clare’s ‘Psychiatry in dissent’ is available in preview here.

Circumstances of diagnosis and the detecting of sanity.

In the experiment eight pseudopatients presented at psychiatric hospitals complaining of hearing a voice.  Asked what the voices said, they replied that the voices were often unclear, but as far as they could tell, said “empty,” “hollow,” and “thud.”  Beyond alleging this symptom, and falsifying their names and vocations, no other falsehoods were told.  Upon admission to the ward the pseudopatients are reported to have ceased to claim symptoms and behaved as they ‘normally’ would. 

Length of hospitalization was an average of 19 days during which time no pseudopatients were identified as fraudulent. All pseudopatients except one (diagnosed with bipolar disorder) were discharged with a diagnosis of ‘schizophrenia in remission’.  In light of this Rosenhan regards there to have been ‘uniform failure to recognise sanity’.  Rosenhan refused to identify the hospitals used on the grounds of his concern for confidentiality.  This is laudable in some respects, but it makes it impossible for anyone at the hospitals in question to corroborate or refute this account of how the pseudopatients acted or were perceived. 

It is a difficulty that Rosenhan seeks to answer whether patients can be identified as ‘sane’ or ‘insane’, whilst psychiatrists, whose practice he wishes to scrutinize, do not make such distinctions in their practice but instead aim to identify and treat what they view as psychiatric disorders.  This objection aside, and working within this terminology, in his 1975 critique Spitzer identifies three possible meanings for ‘detecting of sanity’. 

  1. Recognition, when he is first seen, that the pseudopatient is feigning insanity as he attempts to gain admission to the hospital. This would be detecting sanity in a sane person simulating insanity.
  2. Recognition, after having observed him acting normally during his hospitalization, that the pseudopatient was initially feigning insanity. This would be detecting that the currently sane person never was insane.
  3. Recognition, during hospitalization, that the pseudopatient, though initially appearing to be ‘insane’ was no longer showing signs of psychiatric disturbance.

Only the first two involve identifying a pseudopatient as a fraud and Spitzer feels that it is these that Rosenhan implies are all that are relevant to the central research question.  He disagrees, writing that when the third definition of detecting of sanity is considered Rosenhan’s conclusions cannot be sustained. 

This assertion hinges on Rosenhan’s report that all the pseudopatients were diagnosed as being ‘in remission’, that is recognised as being, currently, without signs of mental disorder or ‘sane’.  By this view the data as reported by Rosenhan contradicts Rosenhan’s own conclusion.  Spitzer also writes that ‘schizophrenia in remission’ was a diagnosis rarely used by psychiatrists at the time of the experiment, and as such this indicates that the diagnoses given were a function of the patients’ behaviours and not simply of the environment in which they were made. 

Should a psychiatrist be able to able to detect that a patient is a fraud?  That is, should a psychiatrist be able to detect that, after observing a patient acting normally, that they were initially feigning insanity?  Rosenhan reports that this possibility was considered by the pseudopatients’ fellow patients but by no clinical staff:

“It was quite common for the patients to “detect” the pseudopatient’s sanity.  During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously.  “You’re not crazy.  You’re a journalist, or a professor (referring to the continual note-taking).  You’re checking up on the hospital.” …. The fact that the patients often recognized normality when staff did not raises important questions.”

Rosenhan reports that the psychiatrists did not spend much time with the pseudopatients.  Other patients of course had ample time to formulate their own theories.  Whilst the medical staff’s lack of engagement with the pseudopatients is regrettable, it does point towards poor clinical skills rather than an indictment of psychiatric classification.  Clare again:

“Rosenhan and those many critics of psychiatry who have greeted his paper with enthusiasm seem in fact to be saying that, since the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever, the whole diagnostic approach should be scrapped!”

Rosenhan later wrote that he considered the patients apparent insight over that of the psychiatrists as due to the ‘experimenter effect’ or ‘expectation bias’.  The professionals expected to see a patient with a mental illness, so they looked for reasons to believe it, and eventually they convinced themselves that the pseudopatients were actually suffering from schizophrenia.

People do sometimes simulate mental illness for their own ends and this is a genuine diagnostic problem.  It is a situation not unique to psychiatry and how easily a disorder psychiatric or otherwise can be feigned tells us little about the worth of the psychiatric classification system.  Kety has something to say on this. 

“If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition”

Clare makes a similar point using the example that the signs and symptoms of diabetes exist independently of whether they are correctly elicited or not. 

Rosenhan does consider in his paper that that a mental illness is a life sentence:

“A broken leg is something one recovers from, but mental illness allegedly endures forever”

If a disorder was known to be always chronic and unremitting, it would illogical not to question the original diagnosis if the patient was later found to be asymptomatic and it is at this that Rosenhan is presumably driving.  If the pseudopatients ‘recovered’ from an incurable illness whilst under the gaze of their psychiatrists and this did not alter the diagnosis then this would be an example, just as Rosenhan says, of the hospital environment influencing diagnostic decision making.  But in stating that mental illness is something that endures forever Rosenhan is taking a very selective view of the wide range of presentations all of which come under the umbrella of ‘schizophrenia’.  Schizophrenia has acute subtypes from which full recovery is possible and can also relapse and remit. 

As for the non-existent impostor experiment it is surprising that it was agreed to by the teaching hospital in question.  The poor reliability of psychiatric diagnoses means that the design of the experiment could only produce an outcome where actual patients were incorrectly identified as pseudopatients. 

Conditions on the ward

All of the pseudopatients took extensive notes.  Rosenhan makes much of this writing being "seen as an aspect of their pathological behaviour” on the grounds of the nursing entry that read “engages in writing behaviour”.  Spitzer argues that was routine for nursing staff to frequently and intentionally comment on non-pathological activities in which a patient engages to enable other staff members to have knowledge of how the patient spends his time.  As such, a comment about note taking is therefore inevitable and unremarkable.  He is struck by what he sees as Rosenhan’s actual failure to provide data demonstrating where normal hospital experiences were categorized as pathological. 

Rosenhan’s account of the conditions on the psychiatric wards is, for me, the most interesting part of the paper.  The staff and patients were strictly segregated, the professional staff and especially the psychiatrists being rarely seen and having little patient contact. 

“Staff and patients are strictly segregated. Staff have their own living space, including their dining facilities, bathrooms, and assembly places. The glassed quarters that contain the professional staff, which the pseudopatients came to call “the cage,” sit out on every dayroom. The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient. Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.”

This description bears resemblance to modern UK psychiatric wards.  Psychiatrists spend little time with the patients in their care and nurses are occupied for a great deal of their time sitting in a locked room doing paperwork.  The healthcare staff members with the most patient contact are the least qualified.  This is far from ideal, and a target for improvement, but it should be noted that within healthcare this distance between staff and patients is not restricted to psychiatric wards and the pressures on staff due to the number of patients in their care means that a more desirable personal service is something with which the NHS struggles in all its domains.

Rosenhan’s description of the depersonalising effect of a long stay on the wards is also powerful.  Despite their commitment to the experiment in which they are taking part, their wish to resist the powerlessness they experience leads several of them to jeopardise the study. 

“The patient is deprived of many of his legal rights by dint of his psychiatric commitment. He is shorn of credibility by virtue of his psychiatric label. His freedom of movement is restricted. He cannot initiate contact with the staff, but may only respond to such overtures as they make. Personal privacy is minimal. Patient quarters and possessions can be entered and examined by any staff member, for whatever reason. His personal history and anguish is available to any staff member (often including the “grey lady” and “candy striper” volunteer) who chooses to read his folder, regardless of their therapeutic relationship to him. His personal hygiene and waste evacuation are often monitored. The water closets have no doors.”

Attendants were reported to deliver verbal and occasional physical abuse to patients, something that can in no way be justified.  Rosenhan’s report of this leads to an interesting inconsistency.  Despite initial descriptions of abusive staff behaviour, in his conclusion Rosenhan describes the staff as overwhelmingly ‘committed and … uncommonly intelligent’.  Spitzer considers that this is because of Rosenhan does not wish to direct attention toward shortcomings of the staff, rather wishing to concentrate on diagnostic labels. 

Validity of diagnosis.

There are two issues here.  Where the psychiatrists who met his pseudopatients wrong to make a diagnosis of schizophrenia within the DSM II diagnostic framework? And are psychiatric diagnoses of use or should they be replaced by an alternative?

The ease with which the pseudopatients gained admission on the basis of what are reported to be mild symptoms was remarked upon by Anthony Clare in Psychiatry in Dissent. 

“It is a matter of some interest that a solitary complaint of a hallucinatory voice in the absence of any other unusual experience or personal discomfort should actually persuade certain American hospitals to open their doors.  Such is the current demand for a psychiatric bed within the National Health Service and the prevailing emphasis on treating patients outside hospitals and in the community that the average admitting doctor in Britain is likely to find himself under strict instructions to avoid admitting any patient who can see, speak, and do all of these things without bothering himself or others to an significant extent.  On suspects that, in Britain, Professor Rosenhan might well be advised to go home like a good man, get a decent night’s rest and come back again in the morning.” 

And many people have been critical of the way the pseudopatients were diagnosed with schizophrenia on the basis of hallucinations – a single symptom and not even essential for the diagnosis.  Anthony Clare again:

“…the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever…”

Spitzer remarks that the doctors should have been wary of making a diagnosis of schizophrenia in a previously unknown patient presenting without any history of insidious onset.  However he is more lenient toward the pseudopatients’ psychiatrists, writing that, given the information available, schizophrenia was the most reasonable diagnosis.  Davis and Weiner agree, respectively arguing from statistical and attribution theory standpoints that schizophrenia was the most likely diagnosis.  Rosenhan himself presents no differential diagnosis. 

Hunter takes exception to Rosenhan’s assertion that the pseudopatients acted ‘normally’ in the hospital:

“The pseudopatients did not behave normally in the hospital.  Had their behaviour been normal, they would have talked to the nurses’ station and said “Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things.  It worked and I was admitted to the hospital but now I would like to be discharged from the hospital”.

We in fact learn very little about the diagnostic process beyond the initial presentations of the pseudopatients.  It should be noted that the pseudopatients would likely not have been, unlike Rosenhan’s assertion, admitted on the basis of their hallucinations solely.  Their presentation to hospital and request for admission may also have carried diagnostic weight as it suggested much greater distress.  However, whatever the fine detail, throughout their stay, the pseudopatients do not appear to have been assessed in detail.

The poor diagnostic skills and apparent lack of curiosity of the psychiatrists that the pseudopatients met is not an indictment of the classification per se, rather its application.   The Rosenhan paper offers no insight as to why psychiatric classification had developed into the shape that he found it in 1973. 

The purpose of a disease classification system is that it allows healthcare professionals to:

  • Communicate with each other about the subject of their concern
  • Avoid unacceptable variations in diagnostic practice
  • Predict their outcome disorders and suggest a treatment.
  • Conduct research

Amongst others Richard Bentall has made a career out of pointing out that psychiatric diagnosis is neither particularly valid nor reliable.  However in Spitzer’s view the historical precedent is that classification in medicine has always been preceded by clinicians using imperfect systems.  These have then improved on the basis of clinical and research experience.  The clinician is forced to do the best he/she can until something better comes along. 

In contrast to psychiatric disorders, the diagnosing of physical medical conditions is often portrayed as being solid and dependable.  This does not bear close inspection, as many medical conditions are at least as vaguely described as psychiatric disorders.  Although it is true that by-and-large a physical illnesses diagnosis rests on biological ‘facts’, the accompanying negative impact on person is the most important factor and this is highly subjective.  For instance we all have bacteria in the back of our throats, but do not consider ourselves to have an infection. 

In light of his experiment, rather than the syndromal classification system, Rosenhan would favour a classification system based on behaviours:

“It seems more useful … to limit our discussions to behaviours, the stimuli that provoke them, and their correlates”

Yet despite this early on in the paper he writes that “Anxiety and depression exist”, suggesting he favours an ad-hoc classification system at least. 

Conclusion

Rosenhan concludes:

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.”

There are sufficient objections to the design of Rosenhan’s experiment – not least that his study consisted of only eight subjects- to doubt whether he is justified in writing his initial sentence.  Rosenhan’s observational study of conditions on psychiatric wards – to which the rest of the above paragraph alludes – still has relevance today and remains a note of caution for anyone who works in mental health.   

Links:

Mind changers 27 July 2009 Radio 4: The pseudopatient study

Scribd: On Being Sane in Insane Places A Critical Review

Evidence based mental health and Web 2.0

Saturday, August 7th, 2010

I have been published in the Journal of Evidence Based Mental health this month.  See previous post for further reading about this subject.

 
Evidence based mental health and Web 2.0

Introduction: Web 1.0 vs Web 2.0

Since its introduction in the early 1990s, the web has evolved significantly. Initially, most websites had a passive user role and either displayed static information or facilitated online transactions. However, recently the web has become more interactive and many of the most popular websites are now online applications which depend heavily on user participation.

This participatory model of web usage has come to be loosely known as ‘Web 2.0’ and the initial non-participatory web correspondingly as ‘Web 1.0’. The term has been popular since 2004 and it is as much ideological as technical. Applications associated with Web 2.0 commonly facilitate the creation and exchange of user generated content. Examples include blogs, social networking sites, wikis and media sharing sites. These sorts of sites have become some of the most visited and discussed about properties on the internet.

Web 2.0 applications are predominately easy to use and free of charge and respond much more rapidly to events than do traditional media. They offer new ways for clinicians to access, share and evaluate healthcare information. Due to their inter-active nature they are constantly evolving and enriching and anyone who uses them assists in their development. However, they also have limitations that need to be understood.

Healthcare professionals have yet to take full advantage of Web 2.0 technologies. In this article I will discuss and critique Web 2.0’s major applications and their potential for the practice of evidence based medicine and mental health.

Web 2.0 applications

Blogs, wikis and microblogs (together with Really Simple Syndication (RSS)) are reviewed ?rst as they have had the greatest impact and share some of the same advantages and disadvantages.

Blogs, RSS, wikis and microblogging

Blogs

The blog was one of the earliest social software tools. Blogs are a very popular form of expression and account for 1.2% of UK internet traffic. They are very easy to start and allow anyone a voice. The term ‘blog’ is a contraction of ‘web log’.

Blogs are an extremely heterogeneous phenomenon. They range in size and seriousness and may be updated from almost constantly to only very infrequently. The majority are maintained by individuals but sometimes there are multiple contributors.

At their simplest blogs resemble an online diary. They can also offer commentary, descriptions of events, or other material such as pictures or video. Despite this diversity, all blogs share common features as follows:

  • The front page of a blog consists of a list of the latest articles or ‘posts’, the most recent first.
  • Old posts are archived by theme and/ or date.
  • Readers can add comments to each blog post allowing an article to be discussed.
  • Blogs are highly interlinked; active bloggers read each other’s blogs and reference other blogs in their own posts.

A blog is written by a blogger and the act of writing a blog is called blogging. Taken together the interconnected community of blogs are referred to as the ‘blogosphere’. Blogs allow groups of people with an interest in a common topic to reflect upon, share and debate their knowledge. Because of this, blogs can often attract a large and dedicated readership.

Many blogs are concerned with medical issues and are useful if one wishes to keep track of an emerging topic more closely than would be possible in a journal. Peer reviewed medical research is often examined by bloggers and this represents an additional further lay and peer review. Following the blogger’s critique this in turn, as well as the research paper, is further critiqued in subsequent reader comments and interlinked posts on other blogs. Posts from blogs discussing peer reviewed research are collated at sites like Researching Blogging.

Although all major journals have web presence, most have shied away from reader contributions to their sites. The British Medical Journal is an exception and has added blogs to its online featured content. It also allows readers to add ‘rapid responses’ to journal articles published online, a facility similar to blog comments.

Syndication – RSS

RSS is a web feed format used to publish frequently updated content such as blog entries, news headlines or podcasts. If a user subscribes to the RSS feeds of a number of sites of interest they then are able to read the collected ‘feed’ on a RSS reader. This avoids the need to check each site of interest individually for updates.

For the clinician, RSS allows a variety of information to be received via a single organised interface. This could include content from the best medical blogs, evidence based sites such as the Cochrane library and newly published content from medical journals

 

Wikis

A wiki is a website that allows collaborative creation and editing of interlinked web pages. These web pages then form a repository of information and knowledge that can be used by large numbers of people. Contributions or modifications can be made by anyone who has been granted access. Wiki means ‘hurry’ in Hawaiian.

 

Anyone can set up a wiki, and the web hosting and software to allow this is easily available and in most cases requires no technical knowledge. The most well-known example of a wiki is Wikipedia. This site is an online encyclopaedia where the content has been contributed by volunteer users working in collaboration. The Wikipedia model offers many advantages over a traditional equivalent. With 15 million available articles, it has a scope which far exceeds even the most expansive printed encyclopaedia. It is free to access and available to anyone with an internet connection. As well as being an encyclopaedia Wikipedia is also a frequently updated news resource as updates appear very quickly. Each article has a discussion page where contributors debate a subject’s most suitable content. Wikipedia can be an excellent place to start researching a subject and one reason for this is that the best articles are referenced by external sources which are often web links themselves. Wikipedia’s accuracy has been found to be similar to that of the encyclopaedia Britannica.

There are several specialist medical wikis available such as Ganfyd and Wikidoc. Alongside Wikipedia they potentially offer up to date, easily accessible medical information.

It is a mistake to think that wikis are only suitable for projects on a grand scale. Any local facility, such as a hospital, could set up a wiki to be used as an easily assess-able and updatable repository of clinical information and local best practice. Many conferences now offer a wiki or blog to facilitate preconference networking.

Microblogging and Twitter

Typically a microblog consists of brief text updates, photos, audio/video clips or links. These are distributed to a group of subscribers via a website or hand held device. Content can be submitted via text messaging, instant messaging or email. Microblogs offer a new electronic communication medium, which can be used to complement those already established such as email.

Here I will concentrate on Twitter, the most popular microblogging plat-form. Twitter is one of the most high profile Web 2.0 applications and is enjoying exponential growth. On Twitter users post frequent short updates (up to 140 characters long) known as ‘tweets’. Tweets are public, but direct private messages can also be sent to other users. Taken together these updates form a chronological list (or feed) which can be viewed on a Twitter profile page or on a hand held device. A user can choose to subscribe or `follow’ another Twitter user’s tweets and this gives a real time picture of what the person they are following is up to or thinking important.

Twitter offers the possibility of a clinician communicating with a large number of knowledgeable peers about clinical questions while ‘on the go’ – there is no need to have desktop or laptop computer access. As such a group will have a wide cross section of knowledge it is possible for a clinician to send out a question to their Twitter net-work and to get the answer they seek very quickly. Because of this for some people Twitter has replaced Google, as they are more likely to ask their Twitter followers when they wish to know something than they are to use the search engine.

Twitter can also be used for mentoring, as a tool to gather data, and for brain-storming and feedback. It can also be used to allow delegates to give reactions to conferences in real time. Many online articles have a facility that allows readers to tweet the article if they find it of use. In this way the number of tweets that an article is awarded allow it to be rated. 

 

Disadvantages of blogs, wikis and Twitter

Blogs, wikis and microblogs all suffer disadvantages for those wishing to undertake evidence based medicine or mental health. Principally, there is no guarantee of authoritative control over their content.

 

Blogs, as they are often written by individuals, are vulnerable to being superficial, to the expression of personal views masquerading as fact and to the echoing of pre-existing data or opinion. Wikis, due to their collaborative nature, are less prone to polarisation, but are particularly vulnerable to vandalism and misinformation – either malicious or due to commercially influence.

Some wikis have sought to minimise this problem by restricting the people who are able to edit their content. The restrictive editorial policy of medical encyclopaedia Ganfyd, as well as some sections of Wikipedia are examples of attempts at quality control. Changes to pages can be monitored and ‘rollback’ allows pages to be reverted to earlier, more correct versions. Others feel that ‘Darwikinism’ in which ‘unfit’ sentences or sections are speedily edited and replaced by other users is remedy enough. However, the time between notification of error and cleanup is still a window of possible harm.
Wiki entries are generally unsuitable for use as academic paper references. A wiki’s content is typically dynamic and wiki authors are often impossible to identify (along with their credentials). The content of blogs is generally more static as blog posts are not generally altered after they are posted. However, the content of a blog is still no more reliable than its administrator.

Tweets are no more verifiable than blog or wiki content. However their nature does make them less likely to be used as reference material over an extended period. Of note is that unlike wikis and blogs, which are often run privately on open source software, Twitter is a proprietary company with a profit motive. It is possible that in the future Twitter may choose to generate revenue from tweets or use account details in ways that run contrary to the preferences of an individual.

Overall, it would be very wise to double check any information gleaned from a blog, wiki or tweet should one wish to rely on it and/or have any doubt about its provenance.

Other web 2.0 sites

Social networking

Online social networking services allow the building of social networks or relations among people. Users who sign up to a social networking site are represented on the site, usually by a profile. Other users who are registered for the service can then potentially access this profile. In this way social links can be made and individuals can share ideas, activities, events and interests either within their individual networks or more publically.

The most popular social networking site is Facebook. Myspace and Bebo are also examples. LinkedIn is a net-working site for professionals and is used for connecting people together in a professional work context. With services like Ning people can set up their own social networks.

In terms of the practice of medicine and healthcare, social networking has had its biggest impact in facilitating the communication of patient groups. Facebook allows individuals to easily set up group pages which allow the sharing of information to interested parties. More specialist patients focused sites allow people to share information about illness experiences and treatment. Revenue is generated by selling the data obtained from the users or by recruiting members for clinical trials conducted by pharmaceutical companies.

Social networking sites do exist for medical doctors, primarily in the USA. Such sites offer the possibility for members to extend their networks electronically to find resources and like-minded colleagues.

 

Social bookmarking

Social bookmarking is a method for web users to organise and share bookmarks of web resources. Unlike file sharing, the resources themselves are not shared, only their web addresses. As well as allowing an individual to bookmark web pages of special interest to them, users can also access bookmarks of other users. This collaborative categorisation of web content is known as folksonomy and has some advantages over categorisation automatically performed by search engines.

Delicious is a popular general social bookmarking site. CiteULike and Connotea are similar but aimed at people wishing to share links to academic papers.

Podcasts, vodcasts and media sharing

Podcasts

Podcasts are audio files that are made available for download over the internet. A listener downloads the files and either plays them on a computer or on a listening device such as an iPod. The video equivalent of a podcast is the ‘vodcast’.

Many podcasts are updated regularly and users subscribe to them using a pro-gram such as iTunes or with an RSS feed. For example, the British Broadcasting Corporation makes podcasts available of many of its radio shows, with listeners downloading the latest instalment every week.

A major advantage of podcasts is that, thanks to small and powerful media playing devices, they can be listened to any-where leading to ‘mobile learning’ and a maximisation of the time available for education. Many well-established publishers of clinical evidence provide pod-casts to complement their journals. It is also possible for individuals to produce and distribute podcasts at low cost.

Video sharing

Video sharing sites allow users to upload, view and share video clips. YouTube is by far the most popular. These video clips can also easily be embedded in other websites. Unlike vodcasts, video clips hosted on YouTube are generally streamed rather than being downloaded. Users can search the website for particular topics or can subscribe to YouTube ‘channels’. There are many YouTube video clips on the subject of mental health and some journals have their own YouTube channels.

Other media sharing

Other media sharing websites allow the sharing of users’ digital photographs, documents and presentations.
Disadvantages of podcasts and media sharing websites

Established content providers such as journals have been active in establishing podcasts and YouTube channels to compliment their written output. These have the advantages of peer reviewed content. Video and audio files shared by individuals have no authoritative control and may or may not be reliable.

Many of these media sharing sites are commercial concerns and this affects the intellectual property rights of media uploaded to them.

Other Web 2.0 sites

Second life is a ‘massive multiplayer online role-playing game’ where users create online representations of themselves (or avatars) and navigate a virtual world much like in a video game. A virtual medical school exists, and online tutorials and conferences are possible.

Health and medicine 2.0

The possibilities suggested by Web 2.0 applications for the practice of medicine and healthcare have lead to the related concepts of Health 2.0 and Medicine 2.0. ‘Health 2.0’ is usually taken to refer to the use of Web 2.0 technologies to promote collaboration between, but not restricted to, patients, medical professionals and caregivers. ‘Medicine 2.0’ is similar in meaning but with an additional focus on science and research. The Health 2.0 movement is entrepreneurial rather than academic.

Web 2.0 and the future of paid content

The advent of World Wide Web and particularly Web 2.0 has lead to a remodelling of how individuals source information. Many people have come to expect their online information to be free of charge. This has particularly affected the newspaper industry, whose publications have generally not yet successfully transitioned to a universally successful postweb model. Most news-papers feel obliged to provide their con-tent to be read online for free as they are concerned that subscription content, to which other sites cannot easily link, will be ignored.

Medical Journals are unlikely to be unaffected by this debate. Most journals require readers to have a subscription although this is not universal. Of the major journals the Canadian Medical Association Journal is free to view and the BMJ and The Lancet have adopted a model where some articles are available with-out charge. The British Journal of Psychiatry makes all its papers free to access after 12 months.

The Web 2.0 paradigm encourages participation and collaboration and has a culture of openness which may lead to the increasing expectation of an equally generous attitude from medical publishing. This demand may gain momentum if further journals encourage reader participation and more empowered patients wish to access the evidence on which their treatment is based. Demand may also come from authors, as the impact of papers may yet become determined by the blog links and Twitter traffic they generate. Contributors may find them-selves frustrated that less important, but more accessible papers, steal the limelight.

Like newspapers, academic journals will need to reach a compromise between the influence and good will that free access brings, versus the revenue that subscriptions generate.

Conclusion

Web 2.0 allows healthcare professions the ability to access, share and debate medical evidence more easily than ever before. The main web applications with relevance to the practice of evidence based healthcare that have emerged from Web 2.0 are blogs, wikis, and Twitter. Podcasts, social bookmarking and media sharing are also of relevance.

The collaborative nature of these applications, together with rapidly developing software and hardware technology, means that their use is still evolving and their impact on the way on the way medicine is practiced is yet to be fully realised.

In comparison with academic printed media, it is more difficult to ensure that information accessed on collaborative media is authoritative. Therefore, although the author would encourage healthcare professionals to use Web 2.0 applications in their practice, users are advised to exercise caution.

Web 2.0 Resources

Blogs

Start your own blog with WordPress (http://wordpress.org/)or Blogger (https://www.blogger.com) software

Frontier Psychiatrist:
http://www.frontierpsychiatrist.co.uk (author’s site)

The Carlat Psychiatry Blog:

http://carlatpsychiatry.blogspot.com/

Shrink Rap:

http://psychiatrist-blog.blogspot.com/

Mindhacks:

http://www.mindhacks.com 

RSS

Web based RSS reader:
http://www.google.com/reader

Desktop RSS reader:
http://www. sharpreader.net/

Wikis

How to start a wiki guide:

http://www.wikihow.com/Start-a-Wiki

It is also possible to start a wiki on Google Sites:

http://www.google.com/sites

Wikipedia:
www.wikipedia.org

Ganfyd:

http://www.ganfyd.org

Wikidoc:

http://www.wikidoc.org

AskDrWiki:

http://askdrwiki.com 

Microblogging

Twitter:

http://www.twitter.com

Author’s Twitter feed:

http://www.twitter.com/psychiatrist

Social networks

Facebook:
http://www.facebook.com

Patientslikeme:

http://www.patientslikeme.com/

Social bookmarking

Delicious:

http://www.delicious.com

Author’s Delicious bookmarks:

http://delicious.com/frontierpsychiatrist

Citeulike:
http://www.citeulike.org/

Connotea:
http://www.connotea.org/

 

Podcasts

Podcasts can be subscribed to using iTunes:

http://www.apple.com/itunes

British Journal of Psychiatry podcasts:
http://www.rcpsych.ac.uk/press/podcasts.aspx

Institute of Psychiatry Podcasts:

http://www.iop.kcl.ac.uk/podcast/

American Journal of Psychiatry podcasts:

http://ajp.psychiatryonline.org/misc/audio.dtl

YouTube

YouTube:
http://www.youtube.com

JAMA YouTube channels:
http://www.youtube.com/user/TheJAMAReport

BMJ YouTube channel:

http://www.youtube.com/user/BMJmedia

Media sharing

Flickr:

http://www.flickr.com

Slideshare:

http://www.slideshare.net/

Scribd:

http://www.scribd.com/

BMJ: A series of unfortunate events

Thursday, February 25th, 2010

soue

I have had an educational piece published in the BMJ today.  You can read it free of charge in the published form here.   It took me an exceptionally long time to write.

***

Endgames case report: “A series of unfortunate events”

Stephen Ginn, psychiatry core training year 3
Ladywell Unit, Lewisham Hospital, London SE13 6LH

A 24 year old man presented to the accident and emergency department because he had been planning to take an overdose, but had decided instead to seek help from mental health services. He had intended to take the contents of several blister packs of paracetamol, together with alcohol. He had been having suicidal thoughts for a week but they had become particularly pronounced over the past two days.

His recent history was one of a “series of unfortunate events” that had left him feeling desperate. Four months ago his flatmate stole money from him, which meant that he was unable to repay several loans. His debtors had started to threaten him and he had been forced to move to a different city and leave his job. He had become socially isolated, and continuing financial difficulties had resulted in poor relations with his new landlord. Just before his presentation he had been awaiting a cheque for housing benefit. However, this had not arrived, and he described this as “the last straw.” He reported feelings of hopelessness and thoughts of “what’s the point?”

He had no history of suicide attempts, self harm, or suicidal thoughts. Five years previously, however, he was admitted twice to a psychiatric ward with psychotic symptoms associated with the use of cannabis. Currently there is no evidence of psychosis, and no relevant medical history. He came to hospital on his own, but a friend provided a collateral history on the telephone. The patient says that if he goes home he is worried that he will take the large amount of paracetamol tablets that await him there.

Questions

1 How would you assess his risk of suicide?
2 How would you manage this patient?
3 What are the general principles of suicide prevention?

Answers

1 How would you assess his risk of suicide?

Short answer:
The likelihood of future suicide should be estimated during an unhurried and sympathetic interview by establishing the motivation for, and circumstances of, the suicidal ideas or act in question, as well as the presence of known risk factors. It is useful to obtain a collateral history from a friend or relative if possible. The three most important risk factors for future suicide are current suicidal intent, history of suicide attempts, and presence of a psychiatric disorder. Once you have inquired after risk factors and have an understanding of the patient’s circumstances you should be able to form an opinion on the patient’s suicide risk.

Long answer:
A suicide risk assessment is normally performed in hospital by psychiatric trainees or psychiatric liaison nurses, although knowledge of risk assessment with suicidal ideation is useful for doctors working in all specialties. This answer is written from the perspective of a psychiatric trainee conducting an assessment in hospital, but assessments elsewhere and under other circumstances follow the same principles.

Before assessing a patient you should establish his or her state of physical health and, if appropriate, level of intoxication. The appropriateness of assessing a patient who is physically unwell, or compromised through drug or alcohol use, is often a cause of friction between psychiatric and non-psychiatric professionals. It may be wise not to see patients who are acutely physically unwell until they have improved, because their physical health may be a more pressing concern and may prevent a satisfactory assessment. However, if the patient is physically stable, then their physical problems need not be a barrier. Although it may not be safe to wait until someone is no longer intoxicated before they are seen, an assessment of mental state performed under these circumstances should ideally be repeated.

When assessing a patient for suicide risk your main task is to gather information that will help you decide whether a future suicide attempt is likely. The first major area to cover in the assessment is the context in which the patient’s suicidal act took place and the motivation behind it. This involves a detailed review of events leading up to the act, the act itself, and the circumstances under which the patient came to hospital. Life events typically precede suicidal acts, with disruption of a relationship with a partner being particularly common.1 The features of the circumstances surrounding the act provide an indication of seriousness and hence chance of it being repeated. The tableGo lists features of an attempt that suggest high and low risk of repetition.

Once the circumstances surrounding a suicidal act have been established, specific risk factors for future suicide must be explored.

The main risk factors indicating continued high risk are:

  • A statement of continued intent. Although clinicians may be reluctant to ask such a blunt question, patients are often surprisingly open about their current state of mind.
  • History of previous suicidal behaviour. Many people who complete suicide have made a previous attempt, and a history of self harm or suicide attempts is present in at least 40% of cases.3 You will need to ask details about previous attempts, such as whether hospital admission was necessary?
  • Presence of a psychiatric disorder. About 90% of people who have completed suicide have a psychiatric disorder at the time of death.3 Affective disorder carries the highest risk of suicide, followed by substance misuse (especially alcohol), and schizophrenia; comorbidity greatly increases risk.3 A key factor linking depression to suicidal acts is hopelessness or pessimism about the future, and this should be included in the history taking.4

To establish the presence of a psychiatric disorder an assessor should inquire after the common symptoms of psychiatric disease, any contact with mental health services, and whether any psychiatric drugs are being prescribed. Clinical descriptions and diagnostic guidelines for mental and behavioural disorders are found in ICD-10 (International Classification of Diseases, 10th revision).5

Once these three main risk factors have been dealt with, further risk factors associated with suicide are:2

Age 25-54 years

  • Male sex
  • Unemployed or retired
  • Poor physical health
  • Separated, divorced, or widowed
  • Living alone
  • Lower socioeconomic class
  • Criminal record
  • History of violence.

Scales are available to help assess the risk factors for suicide, such as the Beck suicidal intent scale6 and the SAD PERSONS scale,7 which has a mnemonic that is easily remembered.

Other areas that must be covered during an assessment include the patient’s medical history, medications, and family history of medical or psychiatric disease. A suicide attempt can be a response to stress learnt by example, and a family history of suicide increases the risk at least twofold, independently of family psychiatric history.8 Personal history should also be sought and include schooling, accommodation, personal relationships, and employment.

It can be useful to talk to a friend or relative to gain a collateral history. When taking such a history, the assessor must remember to respect the patient’s confidentiality. Collateral history is especially valuable if the patient is deliberately trying to mask his or her mental state and seems to be telling you what he or she thinks you want to hear rather than how they actually feel. It is also necessary to evaluate the degree of support available to the patient should they return home. If the patient’s suicide attempt seems to be as a result of a situation at home to which they are proposing to return, this would obviously be of concern.

If in doubt about a patient’s level of risk it is wise to consult a more experienced colleague.

2 How would you manage this patient?

Short answer:
It may be possible to discharge patients who are thought to be at low risk to the care of their general practitioner for follow-up, whereas those with moderate risk will probably need an urgent appointment with a community mental health team or involvement of a home treatment team. Patients thought to be at high risk may need hospital admission and possible assessment under appropriate mental health legislation. Follow-up services will consider whether further interventions—for example, psychotherapy and pharmacotherapy—are appropriate. This patient was thought to be at moderate risk because of continuing suicidal intent and access to lethal drugs. He was admitted informally to a psychiatric inpatient unit.

Long answer:
It is important to make thorough notes on your consultation. Although this is true for any patient encounter, it is even more important here because your record serves as potentially valuable material for future risk assessments should the patient attempt suicide again. The steps taken to protect the patient should also be documented.

Suicidal acts occur for a variety of reasons, and often the primary aim is not death but some other outcome, such as demonstrating distress to other people or seeking change in their behaviour.9 Therefore, the needs of individual patients will vary widely. If you have asked about the risk factors above and have an understanding of the context of the suicidal act then you will have formed an opinion as to a patient’s suicide risk. Any patient with a concerning level of perceived suicide risk will, for a time, need supervision and restriction of access to lethal means. Your assessment will establish to what level and for how long these restrictions should be enacted.

If you think that a patient’s suicide risk is low and you are assured that they have good support in the community, they can be discharged from hospital and followed up by their general practitioner or community mental health team, to whom a copy of your assessment should be sent. A patient discharged home should be advised to attend appropriate services, such as the accident and emergency department, if they or their family are concerned in the future.

You may feel that the suicide risk is moderate. This might be the case for patients who say that they have no continuing suicidal ideation, but in whom you have identified several risk factors for a further attempt. In this situation, although it may be appropriate to discharge the patient from hospital, the local community mental health team should be urgently informed so that they can provide follow-up. Some psychiatric home treatment teams will be willing to see patients at this level of risk.

For any patient you discharge who has had recent suicidal thoughts or has performed suicidal acts you must be convinced that the environment to which they are discharged will be safe and supervised by friends or relatives whom you judge to be reliable, who wish to care for the patient, and who understand their responsibilities.

An example of a patient who is at high suicide risk would be someone who continues to have suicidal intent, has made several previous attempts, and has a psychiatric disorder. Hospital admission is appropriate for such patients. If they refuse the offer of an informal (non-compulsory) hospital admission, you may wish to recommend that they are detained under the relevant mental health legislation.

After their assessment it is the responsibility of the assessing doctor to be confident that, before the end of their shift, the appropriate follow-up services will be provided with all the information that is needed.

3 What are the general principles of suicide prevention?

Short answer:
Two broad approaches to reducing the total number of suicides exist. The first is to take steps at a population level; an example of this is to sell paracetamol in smaller size packs. The second involves targeted strategies, such as evidence based treatments, aimed at high risk groups about whom healthcare professionals should be aware.

Long answer:
The two main approaches for reducing the number of suicides in the population are: preventive strategies that can be applied to the population as a whole and those that are targeted towards high risk groups.

Population strategies10 11:

Improving the ability of primary care doctors to recognise and treat depression and other psychiatric disorders has been shown to be valuable because studies have reported that 16-40% of people who die by suicide have visited a family doctor in the week before their death.12

School based programmes aimed at improving psychological wellbeing could contribute to suicide prevention in young people by increasing knowledge of psychological symptoms and help seeking behaviour.

Gatekeepers are community members, such as clergy, whose contact with potentially vulnerable populations provides an opportunity for them to help identify at risk individuals and then direct them towards appropriate assessment and treatment.

Suicide screening aims to identify people at risk and direct them towards treatment.

Public education campaigns have been aimed at improving understanding of the causes and risk factors for suicidal behaviour and reducing the stigmatisation of mental illness and suicide, with the aim of improving the recognition of suicidal risk and increasing help seeking.

Restricting the availability of the means by which people commit suicide, such as installing safety barriers on bridges, saves lives. Substitution of one method for another can happen, but studies indicate that many people have a preference for a given method.13

The media can help educate the public about suicide, but it can exacerbate matters by glamorising suicide. Restrictions on reporting and codes of conduct can help lower suicide rates.

Strategies applicable to high suicide risk groups10 11:

Some people are at particular risk of suicide, and healthcare professionals should provide these people with treatments that reduce the risk of suicide attempts. Patient groups at particular risk of suicide include people with psychiatric disorders—those who have just been admitted or just been discharged from psychiatric hospital in particular; elderly people; high risk occupational groups, such as medical practitioners, pharmacists, farmers, and vets; and prisoners. Major risk factors for suicide in prisoners are previous attempts, recent suicidal ideation, being in a single cell, presence of a psychiatric disorder, and a history of alcohol problems.

Psychiatric disorders should be treated in high risk patients, and pharmacotherapy and psychotherapy are key treatments. Because of the chronic and recurrent nature of mental illness, and the difficulties in engaging patients with treatment, the best possible acute and long term psychiatric care needs to be available.

Even with near perfect care and risk assessment, and despite the best efforts of friends and professionals, suicide is not something that can be entirely predicted or prevented.

Patient outcome

Our patient was judged to be of moderate-high risk of future suicide. He had been having suicidal thoughts for some time and had a method in mind. If he had been discharged he would have returned to an unresolved stressful social situation with continued access to lethal methods. Particular risk factors for repeat suicide were a possible diagnosis of depression and statement of continued intent. Other risk factors were male sex, social isolation, and unemployment. His friend confirmed his story and said that he had seemed to be low in mood recently.

We thought that there was sufficient cause to warrant an informal inpatient hospital admission. The admission lasted three days, during which time antidepressants were started, his relationship with his landlord improved after the intervention of a social worker, and he denied further suicidal ideation. At the end of his stay he was discharged into the care of a community mental health team.

Further reading

The reader is referred to the relevant NICE guidelines on assessment and management of self harm.14

References

  1. Cavanagh JTO, Owens DGC, Johnstone EC. Life events in suicide and undetermined death in south-east Scotland: a case-control study using the method of psychological autopsy. Soc Psychiatry Psychiatr Epidemiol 1999;34:645-50.[CrossRef][Web of Science][Medline]
  2. Hawton K, Taylor T. Treatment of suicide attempters and prevention of suicide and attempted suicide. In: Gelder M, Andreasen N, Lopez-Ibor J, Geddes J. New Oxford textbook of psychiatry. 2nd ed. Oxford University Press, 2009:969-78.
  3. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33:395-405.[CrossRef][Web of Science][Medline]
  4. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10 year prospective study of patients hospitalised with suicidal ideation. Am J Psychiatry 1985;145:559-63.
  5. WHO. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992.
  6. Beck A, Schuyler D, Herman J. Development of suicidal intent scales. In: Beck A, Resnik H, Letteri DJ. Prediction of suicide. Charles Press, 1974:45-56.
  7. Patterson W, Dohn H, Bird J, Patterson G. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 1983;24:343-9.[Web of Science][Medline]
  8. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160:765-72.[Abstract/Free Full Text]
  9. Hjelmeland H, Hawton K, Nordvik H, Bille-Brahe U, De Leo D, Fekete S, et al. Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav 2002;32:380-93.[CrossRef][Web of Science][Medline]
  10. Hawton K, van Heeringen K. Suicide. Lancet 2009;373:1372-81.[CrossRef][Web of Science][Medline]
  11. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies. A systematic review. JAMA 2005;294:2064-74.[Abstract/Free Full Text]
  12. Pirkis J, Burgess P. Suicide and recency of health care contacts: a systematic review. Br J Psychiatry 1998;173:462-74.[Abstract/Free Full Text]
  13. Daigle MS. Suicide prevention through means restriction: assessing the risk of substitution: a critical review and synthesis. Accid Anal Prev 2005;37:625-32.[CrossRef][Web of Science][Medline]
  14. National Institute for Health and Clinical Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. 2004. www.nice.org.uk/CG016NICEguideline.

Mental state examination

Wednesday, December 9th, 2009

mental state exam

We all meet people in our daily lives and as human beings we are acutely tuned to noticing difference between ourselves and others.  The step between subconscious awareness and conscious noticing and recording as an examination is one of the situations where psychiatrists demonstrate their ability, and arguably it is an area at which psychiatrists are most practiced and skilled.

A psychiatrist’s mental state examination is a systematic way asking patients about their thoughts and feelings so as to reveal and document them.  How one asks such questions, follows up on the answers, records the responses and draws conclusions from them are skills to be learnt and practiced like any other means of examination.  Technical terms to document certain phenomena which would not be known to someone who is not a student of psychopathology.

The success of a mental state examination depends in part on the cooperation and capacity of the patient to follow the psychiatrist’s questions, but cooperation is not essential.  It is more difficult to perform and children and is complicated by any barriers that may exist between psychiatrist and patient such as language and cultural differences.

By convention a mental state examination is recorded under the following headings: Appearance, behaviour, speech, mood, thought, perceptions, cognition and insight.  The mental state examination concerns the patient at a particular moment in time; historical details should not be recorded.

Appearance

In this section try to describe how the patient looks.  It can be useful to consider what would help someone else pick out a person should they need to select them from a room full of people.  Give details of patient’s apparent age, sex, ethnicity, clothing, tattoos, personal hygiene, state of self care, scars and piercings.

Behaviour

Describe what the patient was doing at the time of interview.  Were they engaged in the interview process or did they appear distracted/preoccupied/perplexed? Did they make eye contact?  Where there obvious mannerisms/tics/stereotypes?  You can document things that happen during the interview here, for example if the patient walked out of the interview before it was complete

Speech

nb: The difference between ‘speech’ and ‘thoughts’ in the mental state examination is tricky.  Psychiatrists assume that the content of what is being said by a patient is an expression of the inner process of thinking.  Therefore in ‘speech’ the form of speech is discussed, whereas in ‘thoughts’ the content of someone’s speech is recorded.

What was the rate (fast, slow, pressured), volume (quiet, shoutings) and rhythm of someone’s speech? Were they interruptible? What was the tone (monotonal, angry, agitated)?  Include errors of pronunciation, slurring, punning, rhyming, clang associations.  Was the speech circumstantial/tangential?  Was it goal directed or rambling.

Consider also whether thought disorder is present.  Terms that describe this include loosening of association, knight’s move thinking, word salad, thought block, perseveration and neologisms.

Mood

This can be described under two headings:

Objectively – how the patient appears to you – do they appear elated, flat/blunted, incongruous depressed or anxious?  Is their mood reactive, for example do they smile when talking of something that they enjoy?

Subjectively – how does the patient describe their own mood?  Are they expressing depressive attitudes?  You can ask about the symptoms of depression here if you wish, but as these are often asked about as experienced over the past two weeks, it is best dealt with in the patient’s history I feel.

Thoughts

See note on ‘speech’ above.  What do the preoccupations of the patient appear to be during the interview?  Are there any abnormal beliefs?  Are these delusional or overvalued ideas?  Do they have any paranoid ideation?  Do they think that someone is following them?  Do they have any obsessional ruminations, compulsions or rituals?

Perceptions

Ask here about any abnormal experiences.  Try to get as much information as possible about their content, personal explanations and response to the experience.  A knowledge of hallucinatory experiences is useful here.

Cognition

This is rarely done in practice unless cognition is suspected to be impaired.  It requires a cooperative patient,  and a mini mental state examination is a good place to start.

Insight

It is a feature of a lot of mental illness that someone suffering from it is unaware of their predicament.  Insight is a measure of the patient’s ability to accept that they are ill and is not an ‘all or nothing’ phenomena.  Broadly, insight runs at one extreme from those who are unwilling to accept that they have a mental illness, to those that are willing to consider that their experiences are consistent with mental disorder, to those that are accepting of a psychiatrist’s viewpoint and are compliant with medication.  There are entire books written on this.

The mental state should be tailored to the patient you meet.  With some patients their history may be such that it is sufficient to write ‘no evidence of psychotic symptoms’ under thoughts.  With others you may wish to document that you have asked after specific psychopathology consistent with psychotic illness.

The cartoon is a reminder to keep an open mind about the power relationships between doctors and patient and the risk of drawing erroneous conclusions.  See Margaret Mitchell effect

Mental health act – summary

Sunday, December 6th, 2009

mental health act

Here are some summary points on the mental health act that I wrote for a talk to medical students.  It’s not comprehensive and is intended to cover the basics.

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The Mental Health Act 1983 was amended in 1987 and is legislation governing the formal detention and care of mentally disordered people in hospital.   The 2007 MHA also governs care of some people in the community with ‘Community Treatment Orders’

There are 50 000 compulsory admission in the UK every year.  However most mental health treatment is carried out with patient consent.

When seeking to treat someone with mental health problems the least restrictive option for treatment should always be sought.

The act defines mental disorder as ‘any disorder or disability of mind’ (further discussion)

Note that drug or alcohol dependence are not considered mental disorders but paraphilias are under the scope of the act.

When detaining someone in hospital appropriate treatment must be available for them there and actually available to the patient.

Important people to enactment of mental health leglisation are:

Section 12 doctor – someone approved to make medical recommendations under the act
AMHP (approved mental health professional)  – someone approved by the local authority to perform certain roles under the act
Nearest relative: clearly defined under the act and not the same as next of kin.  See here for details
Responsible clinician: several roles, but mostly renew and discharge detentions.   Since the 2007 Act this is no longer solely the role of a doctor

Types of commonly used sections:

Section 4:  Emergency admission for assessment

Lasts 72 hours
Requires one medical practitioner and AMHP to enact

Section 2: Admission for assessment

Max duration 28 days
Requires two medical practitioners and AMHP to enact

Section 3: Admission for treatment

Maximum duration 6 months, can be renewed
Requires two medical practitioners and AMHP
Nearest relative must consent.

Section 5(2)

Allows detention of an informal patient for up to 72 hours
Designed as an emergency order in order for a mental health act assessment to take place
Doctor does not have to be approved under section 12
One medical recommendation required.  This should be completed by doctor in charge of patient’s care.

Section 136

Allows a police officer to remove someone who appears to be suffering form a mental health disorder to a place of safety
Should not exceed 72 hours and allows patient to be assessed by medical practitioner.

The following people can discharge someone from a section of the MHA

Responsible clinician
Nearest relative (Responsible Clinician has the power to block this)
Mental health tribunal
Hospital managers

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This is a rather brief rundown.  For further details:

Mental health act 1983: Code of practice

Mental health Act manual 2009 – Richard Jones

Hallucinations and Illusions

Wednesday, July 2nd, 2008

 

It’s psychopathology time again, here on planet Frontier Psychiatrist.  It’s been in the family as my brother recently  attempted the Fourteen Peaks Challenge will testify.  This is his story:

‘In June 2008 my friends and me decided to attempt the 14 Peaks Challenge. This involves scaling all 14 peaks in Wales which are in excess of 3000 ft and is a very long walk, taking up to 24 hours to complete.

After driving up from London, our party started walking at about 2am.  By around 4pm the next day I was starting to experience some quite peculiar visual effects.  Every time I looked at a stone, I could immediately pick out an image of a face or the shape of an animal (typically a crocodile).  Whereas normally it would take a conscious effort to see a pattern in an inert object, the comparisons were coming to me thick and fast.  At one point I picked up a piece of quartz convinced that it had the shape of an ancient Egyptian head.

I gave up the walk at around 6pm, having not slept for around 36 hours.  My tougher companions pushed on and walked for another 10 hours.  Their visual hallucinations apparently became much more vivid than mine with objects becoming actual animals and not just resembling them.’

Depending on your bent in life, this either sounds pretty cool, or pretty scary.  Plenty of people pay good money for similar nights out.

Psychiatrists have spent a lot of time classifying abnormal experiences; psychopathology is the study of this.  This is a big subject, so I’m going to gloss over a few bits.

As human beings we have a number of senses and sense organs and the brain interprets the sensory input from these.  Thus, perception consists of two parts – sensation (visual, auditory, tactile, gustatory, olfactory, kinasthetic and proprioceptive) and interpretation (the cognitive element).

But things can go wrong:

1. The stimulus can be perceived as the corresponding object, but not accurately.  For example an object could be perceived as being the wrong size; this is called micropsia or macropsia.

2. The stimulus is perceived as an object, but not corresponding to the source.  That is to say, both the stimulus and object are present, but different from each other.  This is an illusion

3. There is no stimulus, but a perception occurs.  This is a hallucination. 

4. There is a stimulus, but no perception occurs.  This is a negative hallucination.

So, my brother wasn’t hallucinating, but was seeing an illusion.  There are three major types of illusions:

1. Affect illusions:  here the person’s emotional state leads to misperceptions – perhaps being scared leads to the incorrect interpretation of a shadow.

2. Pareidolia: here a person perceives formed objects from ambiguous stimuli, for example seeing Elvis’s head in a cloud. 

3. Completion illusion: here, due to inattention, an incomplete object is perceived as complete.  For example, CCOK might be read as COOK.

Hallucinations

Hallucinations have several important qualities.  They take place in the same space and at the same time as other real perceptions – this is different from a fantasy or imagery, which take place in subjective space, or a dream, which has no real component;  they are experienced as sensations and have all the qualities of a real object from which they are indistinguishable. They are involuntary, so unlike imagery, they are not under conscious control.

Hallucinations can occur in any modality and there are many different types:

Elementary hallucinations are the simplest kind and they are unstructured hallucinations and bear no relation to anything in the natural world.  An example of this is whirring noises in the auditory modality.  In the visual modality, a person with elementary hallucinations might see multicoloured spots.  

 

Auditory hallucinations often occur with psychiatric illness, and auditory hallucinations of voices are one of the first rank symptoms of schizophreniaVisual hallucinations on the other hand are much more common with organic illness and are very uncommon in schizophrenia.  Organic causes for hallucinations include occipital lobe tumours, post concussional states, hepatic failure and dementia.  

Elderly patients with normal consciousness and no brain pathology, but with reduced visual acuity due to ocular problems experience vivid, distinct formed hallucinations, often of men wearing hats.  This is called Charles Bonnet syndromeLilliputian hallucinations involve seeing tiny people or animals.  These can occur with alcohol withdrawal.  

Other sorts of hallucinations: 

Autoscopic hallucinations are the experience of seeing oneself.  This is different from an ‘out of body’ experience, as with the latter the person sees the world and his own body from a vantage point that is other than his physical body.  In autoscopy, the person ‘remains’ in their own body.

Extracampine hallucinations occur outside the field of normal perception.  An example of this would be hearing someone discussing you down the shops which are a mile away.   

Functional Hallucinations is where an external stimulus provokes hallucination, but both hallucination and stimulus are in the same modality but individually perceived.  An example of this would be hearing a voice when the tap is running.  On the other hand, Reflex hallucinations are when hallucinations in one modality are provoked by a stimulus in another modality.  An example would be seeing a elf whenever listening to music.

Formication is a type of haptic hallucination where there is the sensation of animals crawling under the skin.  This is seen in cocaine intoxication.  A character in the beginning of the film ‘A Scanner Darkly’ has a similar problem.

NB:

A pseudohallucination is like a hallucination, but lacks the quality of a perception.  It is a form of vivid imagery.  If someone feels that they are hearing voices in their head, this is a pseudohallucination as it does not have the same qualities as a normal perception. 

Synaesthesia is the perceiving of a stimulus in one modality in a different modality, for example, ‘hearing’ the colour red.  This can happen on taking LSD

Hypnagogic and hypnopompic hallucinations are hallucinations on falling asleep and waking up, respectively.  They may be normal phenomena and are particularly seen in narcolepsy 

Further reading:

Symptoms of the Mind by Femi Oyebode (Buy from Waterstones Amazon)

Formal thought disorder

Monday, May 19th, 2008

Just like when a physician sees a patient and looks for signs of physical illness, when a psychiatrist meets a patient they are looking for signs of psychiatric illness.  This is important because when people are suffering a deterioration in their mental health, they often describe similar experiences and these signs of mental illness are referred to as psychopathology.  When different psychopathological signs are identified and grouped together they can lead to the formation of a psychiatric diagnosis.

One of the most interesting psychopathology signs is formal thought disorder (FTD) which refers to the sort of disorganised speech which is a manifestation of psychosis

When people are describing a patient’s mental state they often write ‘no FTD’ when they wish to convey that the patient is coherent and can make themselves understood.  It’s a little bit more subtle than that; if a patient is intoxicated or delirious they will be incoherent but they will not necessarily be thought disordered.  Thought disorder refers to a particular set of language errors which are seen in psychosis. 

The name is rather strange.  Although it is called ‘formal thought disorder’ it actually refers to what a patient is saying.  The name is historical as when disorders of speech due to psychiatric illness were first being described (Bleuler, amongst others, was important in this), it was felt that disorders of thought form (disorganised speech) and content (delusions) should be considered separately.  Formal thought disorder therefore is a disorder of speech rather than content*.  

Normal human thinking has three characteristics

1. Content: what is being thought about – this would include delusions and obsessional thoughts

2. Form: in what manner, or shape, is the the thought about; abnormalities of the way thoughts are linked together

3. Stream or flow: how it is being thought about – the amount and speed of thinking

Different elements of formal thought disorder have been described. With his early work, Bleuler considered FTD to be when there was a loosening of associations which lead to fragmentary ideas being connected illogically.  This is seen clearly in the picture above.  Confusingly though, there appears to be no consensus about exactly what can be included formal thought disorder; it appears that most people would now use the term ‘thought disorder’ which refers to both errors of form and stream. Content is still considered separately.  

 

Disorder of stream of thought 

(I’ve split up these into disorder of thought form and stream, but several could be argued both ways)

Flight of ideas is when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.  The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have been spoken.  These verbal distractions may be of three kinds: clang associations, puns and rhymes.

Retardation of thinking is often seen in depression, the train of thought is slowed down, although still goal directed.  The opposite is pressure of speech and this is often seen in mania.

Peseveration is the persistent and inappropriate repetition of the same thoughts.  In reply to a question a person may give the correct answer to the first but continue to give the same answer inappropriately to subsequent questions.  This is especially seen in ‘organic’ brain disorders like dementia.

 

Disorders of thought form:

Overinclusion refers to a widening of the boundaries of concepts such that things are grouped together that are not often closely connected.

Loosening of associations denotes a loss of the normal structure of thinking.  The patient’s discourse seems muddled and illogical and does not become clearer with further questioning; there is a lack of general clarity, and the interviewer has the experience that the more he/she tries to clarify the patient’s thinking the less it is understood.  Loosening of associations occurs mostly in schizophrenia

Three kinds of loosening of association have been described:

Knight’s move thinking or derailment where there are odd tangential associations between ideas. 

Talking past the point (= vorbeireden) where the patient seems to get close to the point of discussion, but skirts around it and never actually reaches it

Verbigeration (= word salad = schizophasia = paraphrasia) where speech is reduced to a senseless repetition of sounds and phrases  (this is more of a disorder of thought form)

Circumstantiality is where thinking proceeds slowly with many unnecessary details and digressions, before returning to the point.  This is seen in epilepsy, learning difficulties and obsessional personalities 

Neologisms are words and phrases invented by the patient or a new meaning to a known word

Metonyms are word approximations e.g. paperskate for pen

Derailment (aka entgleisen) is where there is a change in the track of thoughts.  There is perserved, but misdirected determining of tendency/goal of thought)

With drivelling there is a disordered intermixture of the constituent parts of one complex thought

Fusion is where various thoughts are fused together, leading to a loss of goal direction.

Omission is where a thought or part of a thought it is senselessly omitted

Substitution is where one thought fills the gap for another appropriate more ‘fitting-in’ thought.

Concrete thinking is seen as a literalness of expression and understanding, with failed abstraction.  Can be tested by the use of proverbs.

Thought block  refers to the sudden arrest in the flow of thoughts.  The previous idea may then be taken up again or replaced by another thought.

 

As you can tell this is a big subject and I haven’t got onto the historical attempts to characterize schizophrenic thought processes (by Kraepelin, Bleuler, Goldstein, Cameron and Schneider) or the linguistic classification of speech abnormalities in psychosis. 

Further reading

Andreasen NC. Thought, language, and communication disorders. I. A Clinical assessment, definition of terms, and evaluation of their reliability. Archives of General Psychiatry 1979;36(12):1315-21

*Quite why they choose this name though it unclear to me, and if anyone else can shed more light on it I would be grateful.