What does section 328(2) of the Scottish Mental Health Act specifically state not to be mental disorders?
Sexual orientation
Sexual deviancy
Trans-sexualism
Transvestism
Alcohol/drug dependence (unless psychosis develops)
Who can used Emergency Detention?
Who can use the Short Term Detention and Compulsory Treatment Order?
Who can use a Place of Safety order?
Emergency detention - any registered medical practitioner
Short Term Detention/Compulsory Treatment - approved medical practitioners
Place of Safety - only the police
What is an Emergency Detention used for?
Detaining a patient in a (any) hospital for the purposes of permitting a full assessment of the person’s mental state. Does NOT include treatment
Usually done with the consent of a Mental Health Officer, but can proceed without if urgent
How long can a patient be detained with an Emergency Detention order?
Maximum of 72 hours
It must be likely that the patient has a mental disorder. Patient’s ability to make decisions about medical treatment for said disorder must be significantly impaired
Do patients have a right to appeal an Emergency Detention?
Can patients be treated under this order?
NO right of appeal
(If no MHO consent initially, need to specify why)
Does NOT authorise treatment, except in emergency
How long can a patient be detained under a Short Term Detention order?
Can this be appealed by the patient?
STDOs last maximum of 28 days
Patients DO have a right to appeal, and it is done to a Tribunal and Mental Welfare Commission
NB - this form of detention MUST be approved by an MHO, and can only be applied by an approved medical practitioner (AMP)
What approvals must be met in order to instigate a Compulsory Treatment Order?
Can this order be appealed?
Application must be made by a MHO and be supported by 2 medical reports - one from an AMP and the other usually from the patient’s GP
Patients DO have the right to appeal
How long does a Compulsory Treatment Order last?
Does this have to be in hospital?
CTOs can last for up to 6 months
Care plan is prepared by the MHO and consultation team, who can impose residency, attendance to services etc.
Patient can be treated in either the hospital or the community
According to the Tayside Rapid Tranquilisation Policy, if non-pharmacological approaches have failed, how is a patient managed if they have any of the following…
- unknown history
- cardiac disease
- no history of typical antipsychotics
- current illicit drug use
Consider oral therapy of Lorazepam, 1-2mg
If unsuccessful, or if an effect is required in under 30 mins…
Consider IM injection of Lorazepam, 1-2mg
Wait 30 mins and repeat injection once if necessary
According to the Tayside Rapid Tranquilisation Policy, if non-pharmacological approaches have failed, how is a patient managed if they have a confirmed history of significant typical antipsychotic exposure?
Consider oral therapy of Lorazepam, 1-2mg and/or Haloperidol 5mg
If unsuccessful, or if effect required within 30 mins…
Consider IM injection of Lorazepam, 1-2mg
In extreme cases, can give both IM Lorazepam AND Haloperidol 5mg (in separate syringes)
Wait 30 mins and repeat injection(s) once if necessary
Regarding follow-up antipsychotic medications, which class are typically first line?
Which medication is used in treatment resistant illness?
First line - atypicals
Treatment resistant - Clozapine
What are the 4 areas that may be affected in a personality disorder (at least 2 must be affected)?
- cognition i.e. ways of seeing or perceiving events, others or self
- affectivity i.e. the range, intensity, lability and appropriateness of emotional response
- interpersonal functioning
- impulse control
What are some of the features of an Anankastic personality disorder?
(a.k.a. Obsessive-Compulsive)
Feelings of excessive doubt or caution
Preoccupation with details, rules, lists, order, organization or schedule
Perfectionism that interferes with task completion
Excessive conscientiousness and scrupulousness
Excludes pleasure and interpersonal relationships in favour of prioritising productivity
Rigidity and stubornness
Personality disorders can broadly be broken down into ‘Odd and Eccentric’, ‘Dramatic and Emotional’ and ‘Anxious and Fearful’ according to the DSM-5 - which specific personality disorders fall under each of these categories?
Cluster A - Odd and Eccentric - schizoid, paranoid, schizotypal
Cluster B - Dramatic and Emotional - borderline, histrionic (excessive attention seeking), antisocial, narcissistic
Cluster C - Anxious and Fearful - OCD, avoidant, dependent
What % of the general population have a personality disorder?
What is the most common personality disorder?
10.6%
OCD
What personality disorder would be indicated if a patient exhibited 4 or more of the following?…
- suspects without sufficient basis that others are exploiting, harming or deceiving them
- preoccupied with unjustified doubts about loyalty of friends/associates
- reluctant to confide in others because of unwarrented fear that info will be used against them
- reads hidden demeaning or threatening meanings into benign remarks/events
- persistently bears grudges
- perceives attacks on their character that others don’t and very quick to counterattack
- recurrent suspicions regarding fidelity of partner without justification
Paranoid PD (cluster A)
What personality disorder would be indicated if a patient exhibited 4 or more of the following?…
- neither desires nor enjoys close relationships, including family
- almost always chooses solitary activities
- little/no interest in sexual experienes with another person
- takes pleasure in few, if any, activities
- lacks close friends/confidants other than first degree relatives
- appears indifferent to the praise or criticism of others
- shows emotional coldness, detachment or flattened activity
Schizoid (Cluster A)
What personality disorder would be indicated if a patient exhibited 5 or more of the following?…
- instability of interpersonal relationships, self-image, affects and marked impulsivity
- frantic efforts to avoid real or imagined abandonment
- pattern of unstable and intense interpersonal relationships characterised by alternating extremes of idealisation and devaluation
- impulsivity in at least two areas that are potentially self-damaging e.g. sex, spending, substance abuse etc.
- recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour
- affective instability due to marked reactivity of mood
- transient, stress-related paranoid ideation of severe dissociative symptoms
Borderline PD (Cluster B)
NB - ‘borderline’ refers to being between neurotic or psychotic
What are the criteria for a learning disability?
What psychometric assessment is most commonly used to assess if a patient has a learning disability?
IQ < 70
Developmental aetiology i.e. under 18
Deficits in adaptive functioning
Most commonly used assessment is the Weschler Adult Intelligence Scale (WAIS)
What are the various classifications of severity of learning disability?
Borderline - IQ 70+, mental age 12-15
Mild LD - IQ 50-69, mental age 9-12
Moderate LD - IQ 35-49, mental age 6-9
Severe LD - IQ 20-34, mental age 3-6
Profound LD - IQ <20, mental age under 3
What major personality disorder is 3 times more common in people with a learning disability?
Schizophrenia - earlier age of onset is also seen, with negative symptoms being more common
(also Depressive disorders)
What is the triad of symptoms that characterises autistic spectrum disorders?
Abnormal social interaction
Communication impairment
Rigid/restrictive or repetitive behaviours, interests and activities
What 3 things must someone be able to do to have capacity?
Understand and retain the relevant information
Use and weigh that information to make a decision
Communicate that decision
What are the 5 principles of the Adults with Incapacity (Scotland) Act 2000?
- Intervention must benefit the adulty
- Such benefit cannot reasonably be achieved without the intervention
- Take account of past and present wishes
- Consult with other relevant persons
- Encourage the adult to use residual capacity
