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Note: please remember this template should act as a guideline to simplify the authoring of an online patient case study. You may edit the template to add in extra sections or override the guidelines where needed. You need not fill in all sections, just those that are relevant to your scenario. In the boxes, you may include:Scenario details: the facts of the caseExplanation, including underlying knowledge or theory, any alternative diagnoses, distractors Checks on learning (activities, questions, judgements) Links to further resourcesTitle:Crisis pointAuthor:(2006) Dr Bill Cutter, Dr Lisa Page, Prof. David Baker(2017) Dr A DebelleCreation Date:20/09/207Stage:Module:Block:Block Learning Outcomes this scenario addressesPrimary Patient condition this scenario relates to:Self harm, suicide, borderline personality disorderSection 1. Scenario introductionPlease give a brief introduction to the scenario (bearing in mind that most patients present initially to a General Practitioner) that should include a (made-up) name, age and circumstances, the initial complaints of the presenting patient, a brief indication of any previous treatment and history.You are an FY2 working in A&E. You are asked to see a 22 year old woman, Amy Weiss, who has been brought to the Accident and Emergency department by ambulance. The patient has a Glasgow Coma Scale of 9 (E3V2M4) and is unable to give a history, however the ambulance crew have passed on what information they have. The patient is accompanied by a friend, Chloe, who is able to provide some information. The A & E nurse tells you that the patient is suspected to have taken an overdose. The ambulance crew were called to the patient’s address by Chloe, where they found Amy fully dressed, lying on the bed. She was drowsy with pin-point pupils. Several empty strips of medication were found in the bin. An empty bottle of vodka was on the floor. The paramedics have brought these in for your inspection. Initially she was talking incoherently, but during the journey to hospital she has become more drowsy and her respiratory rate has started to fall. Currently it is 11 breaths per minute. Question: what is your differential at this early stage? Give three potentials.Answer:What can cause decreased consciousness and bilateral pin point pupils?Bilateral pin-point pupils are suggestive of opioid intoxication, but can also be caused by anti-psychotics, benzodiazepines and alcohol. This could be due to illicit substance use, alcohol intoxication, accidental or intention overdose of prescription medication, or hypersensitivity to prescription medication. Trauma and brain injury also need to be ruled out, although less likely with bilateral miosis. Other causes of miosis such as Horner’s syndrome are unilateral. Question: what do you need to do first? Give your reasons to justify your decisions. Answer:Consider:how unwell is she based on physical signs?how closely does she need to be monitoreddo you need to notify seniors?Often, patients arrive in A&E unwell and there is very little information to go on. It may not be sensible to spend time gathering a history as Amy’s respiratory effort starts to decline. That said, the more information you have, the better you will be able to give treatment that works. Your chief concern needs to be her low GCS with associated decreased respiratory effort. You should follow an ABCDE approach to assess Amy, right away -airway, breathing, circulation, disability, exposure.Even prior to establishing what she has ingested, if her airway or respiratory effort is compromised, you may need to take steps to support her airway using adjuncts and manoeuvres, administer high flow oxygen, and support her breathing and ventilation with a bag and mask.Amy’s GCS is 9 - the ability for a patient to maintain their own airway is in doubt when GCS drops to 8 or below. Her respiratory rate is not stable, it is falling. She is at high risk of respiratory failure.Amy should be taken to a resus bay where her GCS, airway and vital signs can be constantly monitored and observed, and intubation equipment is immediately available should she cease to maintain her airway or make respiratory effort. The A&E registrar and consultant should be informed, as well as the anaesthetist on-call, to make them aware of the situation. Depending how Amy does, she may need to be transferred to ITU.Question: what aspects of the history are needed ASAP? List three aspects.Answer: 1. Has she taken an overdose? Now Amy is being closely monitored and your seniors are aware of the situation, you need to clarify whether she has taken an overdose or not – the finding of empty medication packets and empty bottle of vodka beside her is not proof that she has self-poisoned, although it is highly suggestive. At present the patient is incapable of giving a history, but Chloe may well have important information so you need to ask her what she knows. Chloe confirms that she believes Amy has taken an overdose as Amy phoned her to tell her as much, which led to Chloe going to the patient’s house and finding her drowsy and incoherent.2. What has she taken?You need to establish what substance the patient has taken and how much. The medication packets might give you a clue but we can’t be sure that this was what was ingested. Amy may have taken other substances as well, including alcohol or benzodiazepines. She may be on other prescription medication. Again, Chloe may have information on this.3. When did she take the overdose?You need to know when the overdose was taken and over how long (i.e single overdose or staggered over more than an hour) in order to plan management. For example a paracetamol overdose that was taken 4 days ago is treated differently from one that was taken half an hour ago. It needs to be noted if the timing of the overdose is uncertain, which is often the case. It is particularly pertinent for paracetamol but for all overdoses, knowing when they took it and the half-life of the ingested substance can help predict whether they are already in the recovery phase or are likely to deteriorate further. TOP TIP: Once you have some idea of what she has taken, or even if it is a guess, consult Toxbase, which will give you a comprehensive guide to half-lives and treatment protocols for all medications in overdose. When on placement ask for the trust’s username and password for Toxbase, it is great source for learning.Section 2: Further historyThis section will provide the student with a further history of the patient based on an interview. You ascertain from the packet the paramedics brought in and from talking to Chloe that Amy has taken up to 40 co-codamol tablets approximately 6 hours ago.She has been moved to resus and is attached to monitoring. High flow oxygen is being administered and her respiration rate is being closely monitored. With all the pain stimulus caused by insertion of a cannula and the moving around, her GCS has picked up a little and her respiration rate has not dipped below 11. Section 3. Patient observation/ examinationYou may ask the students to choose which examination should be undertaken (either from a list of options, or freely chosen) or you may go straight to the examination results. ExaminationExamination resultsExaminationExamination resultsABCDEA - airway. Currently maintaining airway, not tolerating guedel when insertion attempted, gag reflex thus appears intact. B - respiration rate slightly low at 11 bpm. Good air entry throughout. Maintaining sats with high flow oxygen. C - warm peripheries, maintaining HR at 62 bpm, bp 110/60. D - pupils constricted bilaterally. GCS is now 12 E3, V4, M5. BM 4. E - temp 37. No signs of trauma or head injury, old scars visible from self-harm both forearms. Only mild abdominal tenderness, no guarding or rebound. MENTAL STATE EXAMINATION (done once GCS 15): Appearance and behaviour: Young woman with dyed blond hair. Clean hair, skin and clothes. Self harm scars visible on both forearms. Initially hostile and irritable with poor eye contact, however responded well to rapport-building and was more cheerful and a little flippant as interview went on . Continued to be very hostile towards a certain nurse. No psychomotor retardationSpeech: Relevant and coherent, normal rate, tone and volume. Mood: Subjectively she described herself as angry and upset at her boyfriend. Objectively she had a reactive affect and appeared overall euthymic. Thoughts: She showed some preoccupation with her relationship difficulties and with what others would think of her overdose, repeatedly asking if we were going to tell her mother. She did display low self-esteem, saying ‘I’m such a waste of space.” She had hope for the future, no feelings of guilt and no current suicidal ideation. Her thoughts flowed freely and at a normal rate. There was no evidence of delusional beliefs.Perceptions: There was no evidence of perceptual disturbance.Cognition: A brief assessment revealed she was fully orientated in time, place and person.Insight: She felt that she was not depressed and that all she needed to do was ‘get her head round’ not being with her boyfriend. She said that she had been let down by services before and doubted we could help her with her problems. She seemed to minimize the seriousness of what had occurred.Physical examination is generally unremarkable now that the opiate effects are wearing off. She has mild epigastric tenderness as she has been vomiting and took a large amount of alcohol with the overdose. There is no evidence of hepatic failure (unexpected anyway at this stage) – i.e. no jaundice or bleeding (hepatic failure will cause clotting abnormalities as the liver is involved in synthesizing clotting proteins.)Her mental state examination has interesting features. Whilst these do not immediately affect your management, they are of relevance as they give hints about her personality that may become relevant later. For example, Amy displays low self-esteem and one of her major preoccupations is with how others will view the overdose. Her affect changes over the course of the examination, although she continues to remain hostile to those who she feels are judging her (the nurse, more on this later). She clearly self-harms on a frequent basis. She feels let down by others. These features may be important as they raise the possibility that her personality needs further exploration and this will guide the kind of treatment she needs. TOP TIP: MSEs can seem a little puzzling at first. You need to become a shrewd observer and also have a good vocabulary. They should not contain any elements of history (e.g info re:sleep and appetite should be put in the HPC, unless they are sleeping or eating when you examine them!). It is an examination, just like an abdominal exam, it is a snap shot of how the patient is, at the time you examined him or her. However, unlike an abdominal exam, you may need to ask some questions to get to the patient's mental state, you can only examine their mind by asking some questions and noting their response. This doesn’t mean you regurgitate your HPC within the MSE. You may also be able to glean lots of info of a patient’s mental state from observation alone. Appearance and behaviour :Note how kempt they are, and anything other noteworthy about their appearance. Note whether movements are notably fast or slow, or whether there are any abnormal or repetitive movements. Not any laughter or crying etc. Do they appear to be responding to unseen stimuli? Do they engage with you? Were they co-operative? Did they give you eye contact? Did they make you feel uncomfortable for any reason? Did you feel as though you could establish a working rapport? Think of words to describe their manner. Some useful ones - perplexed, distracted, preoccupied, tense, irritable, guarded, hostile, over-familiar, inappropriate, flirtatious, flippant, garrulous, cheerful, jolly, pompous, grandiose, withdrawn, glum, downcast, passive, controlling, dominant, authoritative, diminutive, meek etc.Speech:Could you follow the speech? Was it relevant? were there loads of unnecessary details but they eventually arrived at an answer (circumstantiality) or did it go off on a tangent never to return (tangentiality)? Was their speech spontaneous? Were there long pauses before they answered (latency of response) were there large volumes of speech or one word answers? Did you need to interrupt them? Could you interrupt them? If the volume, rate or tone were abnormal, comment on it. Tone refers to the character of the speech e.g through gritted teeth, hostile, clipped, over-familiar, pompous, etc., as well as variation in tone e.g monotonous.Mood and affect:You need a subjective and objective measure. Ask them how their mood is NOW (not in the last few weeks - that is in the history). You can ask them to rate their mood out of 10. Then examine their affect - is it restricted, blunted, reactive, unstable/labile, etc? That is your objective measure. ‘Reactive’ is the normal baseline, displaying an appropriate array of tone, facial expressions and general manner in response to you and the environment. Thought:Thought examination is categorised into content, form, rate and flow. Content - May include suicidal thoughts, depressive or anxious cognitive distortion or preoccupations etc as well as overvalued ideas or delusional beliefs. You may wish to categorise the delusion if this seems appropriate, for example: persecutory, delusion of reference, grandiose delusion etc. Paranoid is a lazy term with various meanings. If someone is convinced someone or something is doing something negative to them, then this is a persecutory delusion, not ‘paranoia’. You may put thought alienation in here and passivity phenomena, these are specific delusions related to psychotic illness. Form - If you can’t follow their thoughts, they are thought disordered. If you can characterise it, e.g flight of ideas, tangential, so much the better.Flow + Rate - Do their thoughts seem to be flowing freely or are they too fast to follow, or painfully slow. Does the patient seem to be in the middle of a thought, then stop suddenly( ‘thought block’ ) or do they just not seem to have any thoughts at all (‘poverty of thought’)Perception:You can ask if they are experiencing any perceptual disturbances NOW or note if they are responding to unseen stimuli whilst you examine them. Any other info on this should go in the history. CognitionCognition is usually examined initially by noting orientation to time place and person and level of alertness. If there is reason to believe there is a cognitive impairment either temporary or long-term, then this can be noted and if appropriate an MMSE or other bedside tests could be performedInsight:There are various ways to characterise levels of insight , It is good practice to note whether the patient knows something is wrong, knows something is wrong and thinks that this has to do with their mind or mental health, rather than say, a delusional belief, and then note their willingness to accept some form of treatment, that seems reasonable. If they accept they are unwell, try and get a narrative of why they think they became unwell and what they think they need to get better. Just because they don’t fully subscribe to the medical model of mental illness doesn’t mean they have no insight! It is useful to note however whether they agree with your diagnosis and treatment plan and if they disagree, why. Section 4. Investigations & ResultsYou may ask the students to choose which investigations should be undertaken (either immediately or later) and ask about or explain the clinical reasoning for each of the investigations. You may include images or tables of values, etc. Question: What immediate investigations do you need to do and why? Select from the listAnswer: FBC, U&Es, LFTs, clotting, paracetamol and salicylate levels ECG, CXRExplanation: - paracetamol levels - you need try and ascertain approximately how long after ingestion your levels will be (see management and treatment section below)FBCs may give an indication of an acute bleed suggesting undetected trauma or deranged clotting. U&Es as large paracetamol overdoses can cause renal failureLFTS paracetamol overdoses can cause hepatoxicityclotting - one of the important functions of the liver is manufacture of clotting factorsECG , many substances in overdose can cause arrhythmia. Although co-codamol is not know for this, an ECG is standard part of any medical work-up, and if neal failure is a possiblity, an ECG will be needed if there are electrolyte abnormalities CXR - Amy’s GCS was low on arrival and she may have lost control of her airway at some point. A CXR is needed to looks for signs that she may have asiprated, althoguh these may appear later. Results: 4 hour paracetamol level: 110mg/L. This is above the treatment line on the nomogram. See management and treatment section.FBCs, U&Es, LFTS, clotting - all normal. This is to be expected if the overdose was only 4 hours ago. They will need to be repeated after treatment. ECG and CXR - NADQuestion: What else do you need to do simultaneously to these investigations, or as soon as possible?Answer:Collateral history mental state, risk assessment, psycho-social assessmentSection 6. Patient ManagementPlease explain what happens to the patient next (admitted/discharged) in this scenario, and include the treatment régime that the patient has been given including drugs, doses and other advice.Q: What are the likely physiological effects of such an overdose now and over the next few days?Answer:Co-codamol is a combination analgesic containing codeine phosphate and paracetamol. The effect of each pharmaceutical needs to be considered as the toxic effects and the time-scale of each will be different. ALWAYS CONSULT TOXBASE. It is standard procedure to print out the toxbase management guidance and stick it in the notes for everyone’s info. Co-codamol comes in various doses, but always 500g of paracetamol per tablet, with various strengths of codeine. Dose is commonly expressed as: 8/500, 12.8/500 (available over the counter), 15/500 and 30/500 available on prescription only. TOP TIP: Many prescription medications have a street value. Always ask about use of illegally sold meds, as dosages may be unreliable. Patients may be dependent on street-sold prescription meds. Benzodiazepine withdrawal can be life threatening so it is essential to know what your patient is ingesting on a regular basis, prescription or otherwise. Effects of Codeine:Codeine is an opioid analgesic that is similar in structure to morphine, to which it is metabolised after ingestion. It acts on the central nervous system via mu opioid receptors. It is a narcotic, which acts to reduce the overall level of consciousness and may act to suppress the respiratory drive – leading to respiratory arrest at high doses. Typical signs and symptoms of opioid overdose include drowsiness, confusion, physical incoordination, nausea, vomiting and pin-point pupils. Codeine is well absorbed orally with peak drug levels reached about 2-4 hours after ingestion, so Amy is likely over the worse and will continue to improve.Effects of Paracetamol:Paracetamol is a non-opioid analgesic and anti-pyretic. It has early and late effects after overdose. Paracetamol is rapidly absorbed from the gastro-intestinal tract and peak levels are reached between 30 and 60 minutes after ingestion. The early effects can be mild and mainly consist of nausea and vomiting. However, paracetamol can cause severe hepatic cellular damage because the usual enzymes that normally conjugate paracetamol become saturated and an alternative enzymatic pathway, the mixed function oxidases, metabolises the drug. This results in a toxic metabolite N-acetyl-p-benzo-quinone. The damage, which peaks approximately 3 to 4 days after the overdose, can lead to fulminant hepatic failure and death. The aim of early treatment of paracetamol overdose is therefore to ensure that the risk of hepatic damage is minimised with the administration of N-acetly-cystine or ‘NAC’. Monitoring the synthetic function of the liver, via blood tests LFTs, INR and glucose levels as well as renal function is part of the management of paracetamol OD. Q. Briefly outline what you know about the management of a co-codamol overdose, including psychiatric management. Answer:Medical Management of Codeine Overdose:is the same for anyone with a poor respiratory effort, and despite not knowing what Amy has ingested, you have performed the initial steps based on her clinical presentation.Use of the opioid antagonist, naloxone, may be considered to reverse the action of codeine. If using naloxone, care must be exercised in people who are opioid dependent and it is important to remember that the half-life of naloxone is considerably shorter than codeine. An initial improvement in conscious level and respiratory status may be followed by a further deterioration once naloxone has worn off – repeat doses or continuous infusion may be required. TOP TIP: paramedics will often administer naloxone at the scene - always ask, as an alert patient may suddenly deteriorate as the shot of naloxone that was given in the ambulance wears off. Medical management of paracetamol overdoseToxbase has comprehensive guidance on this and should always be consulted. Management will depend on whether this was a:-single, acute overdose-staggered, taken over more than 1 hour-delayed presentation-uncertain time of ingestion-the approximate amount ingested, and patients weight (beware there is separate management guidance for obese patients) We are pretty sure Amy has taken a single acute overdose 4 hours ago. If in doubt we can always take bloods including levels and commence NAC before getting the results.“1. Consider administration of activated charcoal (charcoal dose: 50 g for adults; 1 g/kg body weight for children) if more than 150 mg/kg paracetamol has been taken within 1 hour.2. Wait until 4 hours from ingestion have elapsed. Then take a venous blood sample for urgent measurement of the plasma paracetamol concentration from all patients. Plasma concentrations measured less than 4 hours after ingestion cannot be interpreted. In addition, measure U&Es, creatinine, bicarbonate, LFTs, INR and FBC.3. Assess the risk of severe liver damage from the plasma paracetamol concentration/time from ingestion graph which follows. This has been revised following recent CHM guidance and now includes a single line joining 100 mg/L at 4 hours with 15 mg/L at 15 hours.If the patient has biochemical tests suggesting acute liver injury (e.g. ALT above the upper limit of normal) consider use of acetylcysteine even if the plasma paracetamol concentration is below the at risk line on the nomogram (in cases of severe poisoning the ALT rises rapidly and is commonly abnormal at first presentation to hospital).WARNING: PLEASE CHECK THE UNITS CAREFULLY AND USE THE CORRECT SCALE4. If the patient’s paracetamol concentration is on or above the treatment line, give intravenous acetylcysteine. toxbase or local trust police will give guidance on doses. There is normally no indication to start acetylcysteine without a paracetamol blood concentration provided the result can be obtained and acted upon within 8 hours of ingestion. If there is going to be undue delay in obtaining the paracetamol concentration, treatment should be started if more than 150 mg/kg paracetamol has been ingested.Note that for obese patients (weighing more than 110 kg) the toxic dose in mg/kg should be calculated using 110 kg, rather than their actual weight.TREATMENT MUST BE STARTED WITHIN 8 HOURS IF MAXIMUM PROTECTION IS TO BE OBTAINED5. If the patient is not at risk of liver toxicity (i.e. the paracetamol concentration is below the treatment line; the INR and ALT are normal; and the patient is asymptomatic) no treatment with an antidote is indicated. If acetylcysteine has been started it may then be discontinued. If the patient also has a normal serum creatinine s/he can be discharged with advice to return to hospital if vomiting or abdominal pain occurs. Provide the patient with a Patient Information Sheet. If the patient has an abnormal serum creatinine see management of Acute kidney injury below.6.Management after the 21 hour acetylcysteine infusion has been givenOnce the 21 hour course of antidote has been completed, the patient will usually be medically fit for discharge since, if the treatment was started within the first 8 hours of ingesting the overdose, the risk of subsequent liver or renal damage is very low.Re-check the INR, plasma creatinine, venous pH or plasma bicarbonate and ALT at, or just before, the end of the 21 hours of infusion.”Source - ToxbasePsychiatric management of an overdoserisk assessmentsafe discharge planning TOP TIP: Be mindful that there is variability in the level of psychiatric liaison provision in different hospitals. In some hospitals , it will be the medical teams who perform risk assessments and mental states, as well as using section 5(2) if required. More on this below. Regardless of the provision at your particular hospital, a working knowledge of psychiatric risk assessments is just as essential as knowing how to treat an acute exacerbation of asthma. The prevalence of self-harm, suicide and depression is high and is frequently co-morbid with chronic health conditions. Question - what do you need to cover in your risk assessment? List everything you can think of.Answer:TOP TIP: When assessing a person who has taken an overdose, you need to get a detailed narrative. To make sure you cover all aspects, structure your interview under the broad headings of ‘before’ ‘during’ and ‘after’. Before - contextualise the act. When did this first cross their mind? Was it impulsive or planned? How did they plan? What aspects did they plan?Any research online or elsewhere? Any psychosocial stressors, life events, any specific triggers?How has their mood been recently?Mental state prior immediately prior to act During - in as much details as possible find out exactly what happened and what the thought processes were. You need to cover:Intention of the act, patient’s belief in the lethality of the actprecautions to remain undiscoveredsuicide notelast acts e.g WillIf they took pills, where did they get them from? Did they stock-pile them over days or take whatever was in the cupboard? How long did it take for them to swallow the pills? Did they waver as they were taking them? Did they take them with alcohol? How were they discovered? Who called the ambulance? After - what are their thoughts now? Do they feel relieved to be alive, embarrassed? Do they have hope for the future? Do they have an on-going wish to die? Do they regret the attempt failed? NEXT: As well as getting a before, during and after narrative, which is your ‘history of presenting complaint’ other risk and protective factors need to be elicited to inform the risk assessment and also to inform a treatment plan. These can be elicited by following the structure of a standard psychiatric history which should include: - previous psychiatric history, including self harm and previous attempts, medical history, alcohol/drug history, aspects of personal history, current social circumstances including levels of social support, housing, finances.Question: What risk factors for suicide do you know? Put them in to categories and list all you knowAnswer:1) Psychiatric factorsOne of the strongest risk factors for suicide is previous attempts with clear suicidal intent. a recent study showed: During the study period, 81/1,490 enrollees (5.4%) died by suicide. Of the 81, 48 (59.3%) perished on index attempt; 27 of the surviving 33 index attempt survivors (81.8%) killed themselves within a year. Self-harm also needs to be taken seriously and is a risk factor for suicide. 60% of those that kill themselves have self-harmed. It is likely that self-harm behaviors prime the person psychologically and perhaps neuro-biologically to suicide. (Bateman) Mental illness - 90% of suicides are associated with a psychiatric disorder. Particularly; depression, 15% of those with depression will die by suicide. bipolar disorder, At least 25% to 50% of patients with bipolar disorder attempt suicide at least once.schizophrenia, lifetime risk 5-10%, 10% of those with borderline personality disorder will die by suicide (Bateman). Substance misuse, including alcohol. Alcohol dependence carries a lifetime risk of 4%, but this is normally compounded by depressive illness, making the risk likely much higher. 2) Demographic factorsSex and age:Suicide is the leading cause of death for men under 50 in the UK. Men are three times more likely to die by suicide than women. Those at highest risk are men aged between 40 and 44 years who have a rate of 23.7 deaths per 100,000 population. Those over 65 are also at higher risk. Young adulthood in general is also a risk factor, Suicide is the leading cause of death among young people aged 20-34 years in the UK.socio-economic group: those in poverty or in the more deprived socio-economic groups have significantly higher rates of suicide. That said, the very rich also have higher rates than the general population. employment status: unemployment incurs a higher riskmarriage status: single or divorced status incurs higher risk3) Life events Loss and it’s meaning to the person can increase risk. Loss of job or housing, financial difficulties and mounting debts, as well as bereavement, are worth asking about.Adverse childhood experiences (ACEs) this includes all forms of abuse as well as household challenges growing up such as being a young carer, substance misuse, mental illness or incarceration of a household member. ACEs are now of major public health concern to the WHO. A large body of research shows they not only have detrimental effects on mental health and suicide rates but on risky health behaviors, chronic conditions and life expectancy. 4 or more adverse childhood experiences will increase risk of death by suicide by 12 times. Chronic illness (e.g diabetes, COPD, cancer, IHD, liver disease) is a separate risk factor for suicide, as well as substance misuse. Those with ACEs are at higher risk of both of these, compounding the risk of suicide. The concept of adverse childhood experiences and it’s reverberations throughout the lifecycle is gaining prominence. Routine enquiry into childhood trauma is being encouraged.3) importance of social cohesion This is a protective factor. Those who are employed, involved in the church (or any other community) or with a close family are less likely to complete suicide. A sense of belonging or shared purpose is a strong protective factor. This is likely why suicide rates dropped during WW2. 4) chronic, painful or terminal illness - e.g cancer, COPD, diabetes, neurological conditions etc. Further history: What you find out: She tells you that she was feeling OK until 3 days ago, when her boyfriend suddenly ended their relationship because he had decided to go travelling. She was extremely upset and he has not been answering her calls since. Prior to this event, her slept and appetite had been fine. Her mood is ‘always up and down’. Her energy levels were also up and down, but she was able to derive enjoyment from going out and playing with her dog. Today, she bought some vodka and drank half the bottle and suddenly felt she could no longer carry on without her ex-boyfriend. She went to the bathroom and found her mother’s painkillers and took them all approximately 6 hours before arriving in A & E. She went to sleep, but woke vomiting and was frightened at what she had done. She phoned her friend and told her. She had not written any notes or made any other final acts. She said that she regretted taking the overdose as it has been ‘so shit in hospital’. She says that she did really want to die at the time, but the whole thing was on the ‘spur of the moment.’ She said this was the first time she had taken an overdose, although confirmed that she cuts regularly and has done for years. The last time was a few weeks ago after an argument with a friend. She tells you that she does not have any intention of overdosing again ‘at least for the time-being’. In her past psychiatric history, she tells you that she thinks she was probably depressed in her last year at school because she had fallen out with a friend, and then became preoccupied with the thought that no one liked her at school because of the fall out. Other relevant history is that she lives with her mother, her father died of alcohol-related illness when she was very young. She and her mother have been having a lot of arguments because she ‘is always criticising me.’ She also tells you that she drinks alcohol on Friday and Saturday nights and tends to get drunk to the point that her friends have to carry her home. She uses cocaine sporadically.On direct questioning, she discloses sexual abuse perpetrated by her stepfather when she was 13. She confided in a teacher, the police were notified. Her mother didn’t believe her at first, but eventually came to terms with it and supported her daughter. She cannot remember ever receiving any support from services to deal with this. She currently works in Tesco, she didn’t do particularly well in school and left at 16. Since then she has gone from job to job. She notices that she falls outs with people easily and has a bit of a temper, and this has cost her jobs and got her i trouble at school. Chloe is probably her only close friend. She often feels lonely and a bit empty. Question: What do you need to do next?Answer:Get collateral history. Touching base with those who might be able to support Amy on discharge, or even stay with her for the first 24 hours, will inform discharge planning and risk assessment. Most patients will not mind you speaking to someone else, but some will refuse. If information is required to inform your risk assessment, sympathetically explain that you have a duty to do this, but crucially that you will not give the person any information, rather you will just ask them some questions.In cases where the patient’s life may be in danger, it is reasonable to break confidentiality to a degree that is necessary to satisfy yourself that the patient is not in immediate danger of coming to further harm. Amy tells you that she doesn’t mind you talking to the friend who is with her, and reluctantly agrees that you can talk to her mum although she said “it’ll just give her more ammunition against me.” You speak to her friend who confirms the above details. She also tells you she was very surprised at what happened, as only four hours before they had been out shopping together and Amy had seemed OK.Question: What is your diagnosis? Pick the most likely from these three optionsDiagnosis option 1Acute stress disorderExplanationThis term is used to describe a brief, transient reaction to exceptional physical or mental stress that usually subsides within hours to days. The features vary but may include a ‘daze’ like state with disorientation, withdrawal or agitation. Somatic symptoms of anxiety are common. Persistence of symptoms beyond 1 or 2 days would not be consistent with this diagnosis. Correct (Y/N)Possible as she has only very recently found out that her boyfriend is planning to go abroad. When interviewed by the SHO she was not exhibiting the symptoms described above, so it is possible that the period of acute stress has already passed.Diagnosis option 2DepressionExplanationThere are none of the cardinal features of depression present such as pervasive low mood, low energy and anhedonia. Neither does she have any of the so-called ‘biological symptoms’ of depression. Depressive features are required to be present for at least 2 weeks before a diagnosis of depressive disorder can be madeCorrect (Y/N)NDiagnosis option 3Borderline personality disorder (same as emotionally unstable PD)ExplanationPersonality disorder is a descriptive term for people who have severe and enduring disturbances of personality and behaviour. The difficulties need to be persistent over time and pervasive; causing problems in several areas of functioning - e.g relationships, work over a lifetime. That said, borderline personality disorder does tend to improve for many as they get older, particularly the more impulsive elements. Borderline personality disorder has 9 features, 5 of which need to be present (according to DSM IV). These 9 features are: frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense personal relationships, identify disturbance, impulsivity, recurrent suicidal behaviour gestures or threats, or self-mutilating behaviour, affective instability, chronic feelings of emptiness, inappropriate intense anger or difficulty controlling anger, transient, stress-related paranoid ideation or severe dissociative symptoms. The ‘borderline’ term comes from the fact that those with this disorder, especially when in high distress states, are ‘on the border’ between an affective and psychotic TIP The new DSM V criteria provides a much richer description, but is perhaps less easy to remember. It is an important disorder to know about. The features may lead to repeated attendances in A&E, not only for self-harm but panic attacks, or dissociative symptoms, including non-epileptic seizures. They may also suffer with persistent physical symptoms making them more frequent attenders in GP surgeries or ANY medical specialty clinic. They may often end up on surgical wards for more severe self-harm or persistent abdominal pain, or ITU. NB - not all those with persistent physical symptoms, anxiety symptoms, or dissociative symptoms such as non-epileptic seizures have borderline personality disorder!Personality disorder is also co-morbid with many other psychiatric diagnosis and may maintain other difficulties or complicate treatment. Borderline personality disorder is NOT more common in women, although they are far more likely to receive the diagnosis. Large survey-based studies in both the US and UK have shown that there are equal prevalence rates between the sexes in the community.40-70% of those diagnoses have a history of past sexual abuse. BPD is probably one of the most misunderstood psychiatric disorders. Both within psychiatric settings as well as general medical settings, those with the diagnosis are routinely stigmatised. Correct (Y/N)Possible. Impulsive self-harm is a feature in those with Borderline personality disorder, but it is rarely appropriate to make such a diagnosis after one presentation. Before diagnosis there must be clear, objective evidence of longstanding disturbances of behaviour and affect. In summary, this is not a diagnosis that would be appropriate at this point, but should be kept in mind and explored in a fuller assessment. Management:Question: What is your management plan? Answer:Although the diagnosis is not yet clear, a management plan can still be TIP: Management plans should always be made for the immediate, medium and long-term and cover biological, psychological and social areas. The immediate management has been covered by our ABCDE approach, risk assessment, mental state examination and medical management of the overdose. We have also started to explore psycho-social factors which led up to this overdose with our psychiatric assessment. In terms of mid-term management: Once Amy is medically stable, she will be discharged into the community. There is nil to suggest that her current level of risk would justify impatient admission: she does not have on-going suicidal ideation, intent or plans. She does not live alone, and although her relationship with her mother is strained it may be worth contacting her prior to discharge, with the patient’s permission. The overdose was impulsive and may happen again as a reaction to distressing life events. Therefore, you should work with the patient to make a crisis plan. You could ring her mother and request that all medications in the house are locked away for the time-being and that her mum keeps an eye on her. Enquire as to who she feels she could talk to, and elicit whether she felt she would be able to talk to her mother or ring Chloe if in crisis. Also ask whether she would be able to call crisis lines such as the Samaritans. It can be therapeutic to ask patients themselves how they want to manage their risk and always make sure crisis plans are collaborative. You may wish to discuss alternatives to self-harm such as: squeeze ice cubes/plunge fingers into ice cream\snap a rubber band on the wrist, chew into something strongly flavoured e.g lemon, using red food dye or using red pen can be alternatives if it is the sight of blood that soothes. Ideally, Amy should have some follow-up, even if it is with her GP, to check her mood and risk levels. Given her chronic self-harm and now escalation of risk with an overdose, a referral to the local CMHT for further diagnostic assessment and possible treatment for BPD (if this is what is diagnosed) should be considered. Long-term management will depend on diagnosis. The treatment for BPD is normally carried out in secondary care, within CMHTs, especially if the patient is actively engaged in risky behaviours. Depending on where you are, there may also access to support groups in the community, such as the SUN project in Croydon. The main modality of treatment is various forms of psychotherapy, such as DBT (dialectical behavioural therapy) or MBT (mentalization based therapy). The term mentalisation refers to the ability to reflect upon, and to understand one’s state of mind. Mentalisation is the insightful understanding of what one is feeling, and why. This skill of mentalisation is thought to develop via a caregiver's empathic and insightful response to a child's distress. This means mentalisation is learned through a secure attachment to the caregiver. Insecure attachments limit the development of this important skill which is the case with the majority of people with BPD. MBT seeks to address this. Please see leaflet below regarding MBT. DBT is based on CBT principles but differs in that it offers explanations and acceptance for people with BPD, who feel emotions very intensely. It still works to change unhelpful and harmful behaviors that maintain difficulties, just like CBT. See helpful link below to this from MIND.Medications can be used to treat co-morbid conditions such as depression, but the emphasis of treatment for BPD is psychological. Social interventions, to improve feelings of belonging and purpose are invaluable for all those with mental illness. This can be done via MIND or other charities, engaging in voluntary work, or support to get training or education. Charities can also advise patients how to manage their finances or welfare payments and allocate support workers. The Maudsley runs the SLaM Recovery College, which provides many courses around various aspects of psycho-education and recovery for all. CMHTs also have access to teams that can improve resilience via vocational opportunities. Social services may need to be involved for needs assessments and housing issues, or any safeguarding issues. Don’t forget about family members and carers support. Section 7. Scenario developmentAt this point, there is the opportunity to develop the scenario, to add some twists or to discuss the natural history of the condition. It may be the time to bring in factors relevant to social, legal or ethical issues, public health matters or the natural history of the condition.You may add description and details here, and/or add any questions you would like students to answer here:The nurse attending to Amy comes to you and tells you that she is refusing to talk to her, has tried to pull out her i.v. cannula and said that she’s going to leave before her NAC treatment has commenced. The nurse says that she remembers the patient from a previous attendance when she had cut herself and that in her opinion the patient doesn’t want help and she should be allowed to leave and make room for a patient who didn’t bring the problem on themselves. You urgently go to the patient’s cubicle, where she is putting her jacket on and her friend is pleading with her to stay.You ask the friend if she would mind waiting outside the cubicle and you introduce yourself and ask the patient if she could sit down and talk to you for a while, as you think you may be able to help. The patient doesn’t speak to you or make eye contact and continues to angrily get her things together. She then says, “take this thing out of my fucking arm, I’m going – you people just want to make me feel even worse.” You try to explain that if she leaves, she could become very ill and even die of liver damage, but she continues to try to leave.Question: List three steps to deal with this situation.Answer: You need to: Think safety first. In such situations, think of your own safety, that of the others present and of the patient. If the nurse has met the patient before, clarify whether there is any tendency towards aggression, before going to see the patient. You may want to contact the security staff before attempting to talk to the patient if you are concerned about your safety or theirs. Presence of security staff may antagonise a situation, but it is important to give security staff prior warning that they may be needed, either to protect the patient or you. Attempt to establish a rapport so that you can persuade her to stay - this will be done by empathising with her situation rather than pushing your own agenda3) Think about capacityTOP TIP Empathy - this word is used a lot in communication skills and OSCE teaching. Many students struggle with this, and tend to have revert to stock phrases such as ‘this much be very hard for you’ which rarely comes across as sincere. For most patients in a situation such as the one described, this will likely antagonise things further.It can be very difficult for students to put themselves in patients shoes, and rather than pretending, it may be helpful to acknowledge the clear level of suffering and display a genuine curiously into the patient’s lived experience e.g ‘“ I can’t imagine what you are going through at the moment and I apologise if the experience so far in hospital has made things even worse. I wonder whether you must have been feeling very desperate to get to the point where you took an overdose, have I got that right? It’s my job to listen to how you got to this point so that we can get a sense of the best ways to help you.” This is only an example and everyone develops their individual approach to relating to patients. The important points to remember are:show genuine curiously into a patient’s lived experience, ask careful questions, don’t make assumptions, don’t jump into using a ‘stock phrase’once you have more information about how they are feeling, acknowledge and reflect on the difficulties, and signal that you are trying to put yourself in their shoes and imagine what things are like for them - come ‘alongside’ the patient, always checking if you have got things rightBy acknowledging the patient’s distress and her frustration with her treatment, you have defused the situation. She agrees to stay for her assessment and TIP: Capacity - a working knowledge of the capacity act is essential for any practicing doctor, for example, in A&E, on older adult wards, palliative care and most other settings. The MCA legislation is complex in practice, and there is often debate regarding the issues. This is difficult topic, and the best way to become comfortable is to see the Act in action in various clinical settings, debate in small groups and talk to clinical ethicists, and clinicians that use the Act on a regular basis. The MCA applies to individuals aged 16 and over.The MCA’s primary purpose is to protect individuals’ autonomy to make decisions regarding their treatment and to protect those who are deemed to lack capacity. It is decision-specific.5 statutory principles of the MCA:A person must be assumed to have capacity unless it is established that they lack capacityA person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success A person is not to be treated as unable to make a decision merely because they make an unwise decisionA act done, or decision made, on behalf of a person who lacks capacity, must be done, or made, in their best interestsBefore the act is done, or the decision is made, regard must be had to whether the purpose of the act or the decision can be as effectively achieved in a way that is less restrictive of the person’s right and freedom of action When deciding whether to assess someone’s capacity, you have to have a suspicion that they are unable to make a decision because of an impairment or disturbance of functioning in the mind or brain. So: first establish whether they have an impairment of, or disturbance in the functioning of, their mind or brain, the so called ‘diagnostic test’ although there does not need a specific diagnosis. If someone is irate, or if they are suicidal, many would argue that they do have a temporary disturbance in the functioning of the mind which incapacitates them to make important decisions. However, if it is established the disturbance is temporary, the clinician needs to be able to justify why the decision cannot wait until the circumstances change. Then: establish whether that impairment/disturbance of functioning renders the individual unable to make the specific decision in question themselves. The so called ‘functional test’A person is deemed unable to make the decision themselves if they are unable to do any ONE of the following:understand information which is relevant to the decision to be maderetain that information in their minduse that information as part of the decision-making processcommunicate their decision by any meansSituation like this abound in medical settings where a patient is not allowing you, or it is not possible to formally assess their capacity.In this case, the patient will not engage in any discussion and will not listen to medical facts regarding her health and risks. She has been unable to demonstrate that they can understand, retain or use the information in a decision-making process. Given the risks are substantial, and she is about to leave the ward, one cannot wait until she is calmer. An immediate judgement on her capacity based on her mental state is needed and justified.Having determined that the patient lacks capacity and that the treatment is potentially vital to save their life, you would be justified in detaining and treating the patient under the Mental Capacity Act, where you consider that such action is in her best interests. In order to do this, the security staff should be urgently called and asked to prevent her from leaving. If necessary, oral/intramuscular sedation may be necessary in order to reduce her level of agitation. Note - the capacity act allows for both restraint and treatment, using least restrictive options and always within a patient’s best interests. The next question is whether to request a Mental Health Act assessment. A section 5(2) is a ‘holding power’ only. It does not legislate regarding treatment. It is used if the doctor feels the patient may well have a mental disorder and the risks to self and others necessitate the patient being held without their consent whilst a MHA assessment is arranged. The patient must be refusing to stay voluntarily. Section 5(2) last 72 hours and the purpose is to allow time to arrange a MHA assessment only. Question What do you know about how those who have harmed themselves are treated by medical staff? Write what you know. Answer:’The experience of care for people who self-harm is often unacceptable’ - NICE Service users can experience indifference and frustration from staff, such as in this scenario, with an attitude that because the harm was self-inflicted they do not deserve care. Other service users have told of assault and dehumanising treatment, such as having stitches done without anaesthesia. An article written by a service user can be found in the useful links section. The NICE guidelines for self-harm state: “People who have self-harmed should be treated with the same care, respect and privacy as any patient. In addition, healthcare professionals should take full account of the likely distress associated with self-harm.” Question: What is self-harm? What self-harm behaviours do you know?Answer: A helpful definition is: “an action intended to do physical harm to the body without intending to die, which serves a short-term function.” NB: Self-Harm is certainly not limited to those with borderline personality disorder. Self-harm behaviours include (but are not limited to):taking too many tablets/overdosingswallowing poisons or caustic substances such as bleachcuttingscratching skinburning skin (e.g with cigarettes or caustic substances)banging headhitting/punching selfthrowing body against somethingstarting confrontation so as to be physically beatenjumping from heightpulling hair outpreventing wounds from healingmaking medical situations worse (e.g not taking insulin as prescribed)stabbing selfinserting foreign objects into bodyswallowing objectsQuestion: Why do people self-harm? Write what you know or take a guess. Answer: Most self-harm that occurs is a private action and accounts for the large majority of self harm behaviours. The purpose of the self-harm is achieved without anybody having to know about the self-harm. It is a way of dealing with internal distress.change emotion pain into physicalmake invisible emotional pain visibledistractdeal with high anxietydeal with high levels of angerpunch oneselffeel something, prevent feeling of numbnessfeel grounded or wholefeel in controlcare for oneself (look after wound carefully)More rarely, patients may deal with internal distress indirectly, that is, via the signal the action gives to others. The purpose of the self-harm can only be achieved if others know about it. In these, rarer cases self-harm is used to:communicate to othersfeel heardattract caring responses from othersget access to mental health servicescontrol otherspunish othersQuote from a service user:“Initially, when I started self-harming, the sole intention was to distract from the intense distressing emotions I was feeling and to regain a sense of control. My self-harm was very measured and controlled, to ensure I stopped just short of requiring medical intervention so that no other person would know I was self-harming. However, I quickly discovered my incredible need, or perceived need, to be cared and helped would be met by professionals if I self-harmed or threatened to self-harm’Section 8. Scenario review This is an opportunity to look over the scenario and ask the student to summarise the position that has been reached or to do a task such as write out the drug chart, send a discharge letter, speak to the relatives etc. You may add description and details here, and/or add any questions you would like students to answer here:Example:Dear Dr X,Re: Amy Weiss; DOB: 12/12/1997This 20-year-old was brought by LAS to St Elsewhere’s on 28 December, 2017 having taken an impulsive overdose of up to 40 co-codamol tablets that day, dosage unknown. This was in the context of relationship difficulties. On arrival her GCS was 9 with respiratory depression but did not require intubation. She required N-acetylcysteine infusion, but attempted self-discharge. She did eventually consent and made a good recovery She was discharged the next day with normal liver and renal function.The overdose took place in the context of her relationship breaking up and having consumed a large quantity of vodka. It was not planned, there were no final acts, and although her intent was to die, she telephoned a friend to inform her of what had happened. She subsequently regretted the overdose, and although displays some ambivalence, she has no concrete intent or plans to attempt suicide. She frequently self-harms by cutting as a way of managing her distress.On mental state examination she was well kempt. She displayed some affective instability. Although she is struggling with low self-esteem, there was little to suggest a clinical depression. She remains at high risk of impulsive suicidal acts, especially in, the context of alcohol. She has a strained relationship with her mother with whom she lives, but agreed for me to include her in a crisis plan. This includes keeping medication in the house out of reach and calling her friend when in distress. I have also supplied Amy with crisis line numbers. Given her long term self-harm which has now escalated to an overdose with suicidal intent, I will be referring Amy to her local CMHT for further diagnostic assessment and treatment. I would be grateful however if she could be seen by yourself in the meantime for mental state examination and risk assessment.I would naturally be happy to discuss her case if you wished,Yours sincerely,Dr JonesSection 9. Extra resources to include for students:Please add any links and references or recommended reading, textbooks that you feel are relevant to this current scenario and the issues that it addresses.MIND website pages on BPD including videos from service users. college info on BPD + self-harm with video guidelines on self-harm article on service user experience of A&E following self-harmcontent/353/bmj.i1150DSM V diagnostic criteria for a richer description of the symptoms -requires log in (service users network) community based crisis and support group on MBT J. Michael Bostwick, Chaitanya Pabbati, Jennifer R. Geske, Alastair J. McKean. Suicide Attempt as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew. American Journal of Psychiatry, 2016; appi.ajp.2016.1 DOI: 10.1176/appi.ajp.2016.15070854Cowen P, Harrison P, Harrison PJ, Burns T. Shorter Oxford textbook of psychiatry. Oxford University Press; 2012 Aug 9.Taylor D, Paton C, Kapur S. The Maudsley prescribing guidelines in psychiatry. John Wiley & Sons; 2015 Feb 23.Skegg K. Self-harm. The Lancet. 2005 Oct 28;366(9495):1471-83.(05)67600-3National Institute for Health and Clinical Excellence. Borderline personality disorder: recognition and management. 2009 Soomro GM, Kakhi S. Deliberate self-harm (and attempted suicide). Systematic review 1012. BMJ Clinical Evidence JM, V?llm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: Health Organization. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. World Health Organization; 1993 Nov 1. ................
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