PSYCHIATRY OVERVIEW: AN ALL ENCOMPASSING CASE

Transcription

1 PSYCHIATRY OVERVIEW: AN ALL ENCOMPASSING CASE Dr Nduka Nzekwue Psychiatric CT2 South London and the Maudsley Trust

2 OVERVIEW Settings and Specialities within psychiatry Frameworks underpinning psychiatric practice Psychiatric history structure recap BREAK Case 1 Questions and Discussion throughout!

3 MENTAL HEALTH SETTINGS

4 SETTINGS OUTPATIENT - Community Mental Health Teams (CAGs) - Home Treatment / Outreach Teams - Outpatient Clinics delivered from Mental Health Hospitals - Tertiary Specialist Mental Health Centres

5 SETTINGS - INPATIENT Acute Hospitals (DGH, Teaching hosp etc) Mental Health Hospitals Forensic Hospitals

6 SETTINGS THE INBETWEEN A&E Place of Safety (Section 136) Therapeutic Communities Prison

7 SPECIALITIES

8 SPECIALITIES General Adult Addictions Forensic Old Age Child and Adolescent Mental Health Services Neuropsychiatry Perinatal Learning Difficulties Psychotherapy

9 GENERAL ADULT PSYCHIATRY Age (generally) Inpatient Services cover all conditions Outpatient services split into the aforementioned CAGs - Psychosis - Mood, Anxiety and Personality - Addiction

10 ADDICTIONS Usually under the General Adult Umbrella Standalone commissioning for Dependence Inpatient services - Acute Assessment Units (AAU) Outpatient services: - Community Drug and Alcohol Teams (CDAT) - Pharmacies prescribing Methadone - Support Groups - Homeless/Community drop in centres - Outpatient clinic/cross speciality advice e.g. Gambling disorders

11 OLD AGE 65 plus Dementia, Psychosis, MAP Physical co-morbidities and functional requirements Inpatient services: Mental Health Hosp old age ward Outpatient: - Community Mental Health Team - Memory Clinics -Support/Social Engagement groups

12 CHILD AND ADOLESCENT MENTAL HEALTH SERVICES 18 and under Behaviour causes and management Developmental disorders, Mood, Anxiety, Personality, Psychosis Inpatient services: CAMHs wards Outpatient services: - Early Years - Under 12s CAMHS - Adolescent - subspecialties (eating disorder, personality) - Psychology (CBT, Family therapy)

13 PSYCHOTHERAPY Integrating Access to Psychological Therapies (IAPT) Integrated Psychological Therapy team (IPTT) Types of therapy offered - CBT, CAT, DBT, Mentalisation, Mindfulness, Group Therapy, Couples Therapy Inpatient: Clinical Psychologist Outpatient settings: Psychotherapy Clinics, Primary Care

14 TO SAVE TIME... Perinatal services - Known psychiatric history, develop post natal psychiatric symptoms - Inpatient referrals and reviews on postnatal wards - Outpatient clinics: Learning Difficulties - General Intellectual functioning, - Concurrent psychiatric+/- developmental disorders - Diagnostic Overshadowing Forensic - Conduct Disorder (previous Oppositional Defiant Disorder) - Known psychiatric history, develop symptoms postincarceration

15 MENTAL HEALTH WORKERS Psychiatrists Core Trainees and SpRs Mental Health Nurses Psychiatric Liaison Nurses (PLNs) Registered Medical Health Nurses (RMNs) Community Psychiatric Nurse (CPNs) Care Co-ordinators Psychologists/Therapists Pharmacist Admin, Managers, Hospital Transport

16 A FRAMEWORK TO BIND THEM... Mental Health Act 1983 (Sections) Mental Capacity Act 2005 (David s pillars of capacity) Deprivation of Liberty Safeguarding Act Childrens Act 1989 ICD -10, DSM V, Maudsley Prescribing Guidelines, NICE guidelines

17 PRINCIPLES OF MANAGEMENT Conservative - Observation - Talking therapies (high intensity) - Focused allied health involvement Pharmacological - Antidepressant, Antipsychotics, Mood Stabilisers, Sedative/hypnotic, Psychostimulants, Dementia meds) -Important pharmacokinetic/dynamic issues -Monitoring and side effects

18 LET S BREAK!

19 PSYCHIATRIC HISTORY 1. Who are you (superficial)? 2. How you get here? 3. What s happened? 4. Seen psych before? Who? How? Where? What happened? 5. What you taken/taking? 6. Physical Problems? 7. Who are you (deep)? 8. How do you live? 9. Examination

20 MENTAL STATE EXAMINATION A B S M T P C I R

21 MENTAL STATE EXAMINATION Appearance Behaviour Speech Mood Thoughts Perception Cognition Insight Risk

22 MENTAL STATE EXAMINATION Discussion How might each aspect relate to a particular diagnosis?

23 AN ALL ENCOMPASSING CASE Ms X is a 37 carribbean who was referred by her dermatologist concerned about low and significant somatic symptoms PC I m low in mood, I m in pain and I keep getting bounced around from doctor to doctor HPC - Low mood and biological symptoms - Physical disability - Neurological symptoms (leg weakness, hand tremor +reduced sensation, LOC, headache) - Musculoskeletal symptoms - Cognitive concerns: word finding diff, forgetfullness (meals, landmarks) - Feels Claustrophobic re: others in her home, large crowds (suppresses bursting into tears), - What do you think so far? Any Questions regarding HPC?

24 AN ALL ENCOMPASSING CASE PPH - Childhood dissociative episodes - Self harm during teens (cigarette burns, superficial cutting) - 6 yr hx GP managed Depression (refused antidepressants, CBTx2, CAT in 2014) - Overdose in 2004 after given a diagnosis of... D&A Nil ETOH or illicit substances FH Mother MI (2014), Rickets Dad Parkinsons (2014), Spinal tumour, Tx for Guillian Barre in 2014 Brother Epilepsy, childhood ADHD

25 AN ALL ENCOMPASSING CASE PMH -Rheumatology team and Pain team managed... -Osteopenia, Osteophytic shoulder growths -IBS (failed OGD in 2012) -Mobitz heart block on a 24hr ECG in Recurrent chest and ear infections PH -UK born, 4 siblings, 2 half siblings, no birthing problems/dd -Ostracised, introverted, emotional and physical abuse from siblings and parents growing. They are all tired of her now. -Schooled till 16yrs, sick frequently, attended college -Employed in retail, performed well, with swift promotions, under stimulated

26 AN ALL ENCOMPASSING CASE SH -ADL assisted by mother and carer - Home OT assessed and modifications in place MSE... discussion Her recovery aims: - Not looking like this - Someone to share her life - Better caring from her family

27 AN ALL ENCOMPASSING CASE Why discuss this case if there are so many possiblities and no confirmed diagnosis Her presentation encompasses many areas of psychiatry: - Mood - Personality - Anxiety / Phobia - Memory Impairment - Functional disorders: Somatisation, Factitious Disorder AS WELL AS...

28 AN ALL ENCOMPASSING CASE A penumbra of possible physical health comorbitidities that either - Cause her presentation - Exacerbate her psychological distress - Could be caused by her psychological distress

29 SUMMARY Psychiatry manages Mental Health in a number of domains and settings There are avariety of ways patients present and settings in which they are managed These are underpinned by certain structured frameworks Psychiatric conditions can cause physical manifestations and vice versa Ambiguity of presentation can be removed by focussed history taking, collaborative working, stringent diagnositic criteria and evidence based physical, psychological and functional management

30 QUESTIONS?