Download Thought Content - International Panel Physicians Association

Mental Health
Paul Douglas
March 30 2017
Purpose of session
- Highlight the importance of the mental health assessment as part of
the overall Immigration Medical Examination (IME)
- How to carry out a Mental Status Evaluation (MSE)
- Symptoms and signs to look out for in migrants with mental disorders
and substance use disorders
- Who may need further assessment
Overview of session
• Why it is important to know about mental health
• What is mental health?
• Classifications of mental disorder
• Assessment of mental health
• Special considerations for travel
Mental health context for IME
- Dimension of the problem
Mental Health - context
• Quick Quiz
Mental health context for IME
- Dimension of the problem
- Stress
Mental Health - stress
• Stress is a condition or feeling experienced when a person perceives that
demands exceed the personal and social resources the individual is able to
mobilise.
• Stress is the physiological response of the body to physical and psychological
demands.
• The level of stress experienced depends on individual reactions to a situation
• The source of stress, or stressor, can be either real or imagined
• People feel little stress when they have the time, experience and resources to
manage a situation.
• They feel great stress when they think they can't handle the demands
• Stress is therefore MOSTLY a negative experience.
Mental Health – stress sources
1. Psychological stressors can be:
• Stressors that cause frustration (blocked from reaching a goal)
• Stressors that cause pressure (responsibilities that tax your abilities)
• Stressors that cause conflict (torn between two or more courses of action)
2. Causes:
• Work-related – demands, role ambiguities or conflicts, ethical dilemmas,
interpersonal problems, career development, physical settings
• Personal - family events, economic difficulties, individual’s needs, capabilities
and/or personality
3. Signs:
• Physical – headache, back pain, fatigue, aches and pains
• Mental - difficulty concentrating, increased errors, poor decision making
Mental Health – stress individual consequences
Psychological
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Anxiety
Depression
Low self-esteem
Sleeplessness
Frustration
Family problems
Burnout
Stress
Behavioural
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Excessive smoking
Substance abuse
Accident proneness
Appetite disorders
Violence
Physiological
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High blood pressure
Muscle tension
Headaches
Ulcers
Skin diseases
Impaired immune
systems
• Musculoskeletal
disorders
• Heart disease
• Cancer
Mental Health - stress
MYTHS ABOUT STRESS:
• All stress is bad
• Stress will not hurt you
• What stresses you out also stresses me out
• No symptoms, no stress
• Only major symptoms of stress are harmful
Stress Model
Mental Health – stress model
Stress response
Stressor
Restores balance
Creates imbalance
Body’s energy
supply
Mental health context for IME
- Dimension of the problem
- Stress – Is NOT an issue for IME!!!!! (unless…….)
- Country requirements and assistance for settlement
Mental health context for IME
• While the USA is the only country that the legislation specifies
inadmissibility for mental disorders with associated harmful
behaviour,
• it is just as relevant to other countries where for :
• Australia – danger to community and cost [our regulation covered by
4005(b)(c)]
• Canada –similar to Australia (threat to public safety and/or excessive demand)
• New Zealand – cost??
• United Kingdom – relevant to refugee population mainly for resettlement
purposes (piloting the GMHAT tool)
• Assist in settlement – Australia’s new tool in eMedical for refugees
Mental Health - definitions
• Mental health is defined as a state of well-being in which every
individual :
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realises his or her own potential,
can cope with the normal stresses of life,
can work productively and fruitfully, and
is able to make a contribution to his or her community1
• "Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.“ – positive aspects
• Mental disorders are generally characterised by some combination of
abnormal thoughts, emotions, behaviour and relationships with
others.
www.who.int/topics/mental_disorders/
Mental disorder are peculiar
• Affect mood, emotions & thinking ultimately leading to change in
behaviour.
• May be inappropriate or harmful behaviour, posing risk to public
safety.
• Chronic in nature, requiring long-term follow up
• May be functionally debilitating and incapacitating, requiring
institutionalisation or special therapies (speech, occupational therapies,
special schooling, vocational skills training) and can be huge burden to
health care systems.
• No biological markers….
Mental Disorders
• Governed by two systems of Classification:
• DSM - American Psychiatric Association (APA)
• ICD – World Health Organization (WHO)
• The classification of mental disorders, (psychiatric nosology or
psychiatric taxonomy), groups symptomatology into various clusters
of criteria leading to diagnosis of various disorders.
• Allows international consistency and standardisation
International Classification of Diseases (Chap. V)
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F0: Organic, including symptomatic, mental disorders
F1: Mental and behavioural disorders due to use of psychoactive substances
F2: Schizophrenia, schizotypal and delusional disorders
F3: Mood [affective] disorders
F4: Neurotic, stress-related and somatoform disorders
• F5: Behavioural syndromes associated with physiological disturbances and
physical factors
• F6: Disorders of personality and behaviour in adult persons
• F7: Mental retardation
• F8: Disorders of psychological development
• F9: Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
In addition, a group of "unspecified mental disorders".
Diagnostic and Statistical Manual (DSM-5)
• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other
Psychotic Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related
Disorders
• Trauma- and Stressor-Related
Disorders
• Dissociative Disorders
• Somatic Symptom Disorders
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Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control and
Conduct Disorders
• Substance Use and Addictive
Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilic Disorders
• Other Disorders
Other categorisations of mental illness?
• Can be an illness (patient perception) or disease (medical diagnosis) of the
mind.
• It is also the psychological state of someone who has emotional or
behavioural problems
• Types of Mental Illness:
• Mood disorders, eating disorders, anxiety disorders, psychotic disorders, substance
dependency, organic disorders, development disorders and personality disorders
• Causes of Mental Illness:
• Genetics, infections, long term Substance Abuse
https://prezi.com/
Detecting mental health concerns?
• Observation through process of IME
• History
• Exam
• Tools/screening
• Further assessments (specialists/tests)
Mental Health assessment - observation
Mental health evaluation begins at the first point of contact
• All staff including security, administrative, laboratory personnel etc.,
• Trained and sensitised on specific indicators to observe
• appearance,
• attitude
• behaviour
Some observations that may indicate a problem include: unkempt,
withdrawn, mute, restless, agitated, confused and aggressive
If abnormal behaviour identified, this should be reported to Panel
Physician and ensure safety of applicant and other clients if required
Mental Health assessment - history
Starts with general data such as name, age, gender, marital status, occupation,
religious affiliation etc.
If history of a mental disorder:
• Symptoms – onset; duration; precipitating event; change over time,
• Impacts on the applicant’s life activities i.e. work, important relationships and extent of
incapacity
• The nature of dysfunction e.g. changes in personality, memory or speech
• Presence of any harmful behaviours
• Type of treatment received and compliance (including hospitalisation and medication)
• Family history
• Note: medical conditions mistaken for a primary psychiatric disorder (e.g.
hypothyroidism treated with steroids can lead to mania)
Mental Health – history specific enquiry
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Pre and perinatal history.
Early developmental history (developmental milestones)
Middle childhood (3-11 years).
Adolescent period:
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b.
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Behaviours and social activities
School history
Cognitive and motor development
Emotional and social development/issues
Young adulthood especially occupational
Marital and social
Alcohol and substance abuse
(Military, Legal, Schooling, Employment, Sexual, Drugs….)
Mental Health – alcohol and substance abuse
• Which substance is used, how much, how frequently?
• Is an increasing amount of the substance required to achieve the ‘high’?
• Is there compulsive long-term use of the substance despite significant
substance-related physical, psychological, social, occupational or
behavioural problems?
• Are there any adverse effects suffered when the use of the substance is
reduced or stopped?
Cage questionnaire (alcohol dependency suspected > 2):
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Have you ever felt that you should Cut down on your drinking?
Have people ever Annoyed you by criticising your drinking
Have you ever felt bad or Guilty about drinking?
Have you ever taken a drink first thing in the morning (Eye-opener) to steady your
nerves or get rid of the hangover?
Mental status examination (MSE)
Following history should conduct an “activities assessment” - ability to carry
out functions of daily living
• Practical skills:
o bathing/washing, dressing, feeding/drinking,
o personal care such as bladder and bowel control (is there urine or stool
incontinence?)
• Conceptual skills:
o learning difficulties; is special schooling required?
o special considerations for job placement?
o conceptual skills such as language, problem-solving, money and time management?
• Social skills:
o communication difficulties;
o can they live alone?
Mental status examination (MSE)
1. Appearance
2. Attitude (towards the examiner )
3. Behaviour and psychomotor activity
4. Speech
5. Mood and affect
6. Perception
7. Thought processes
8. Thought content
9. Alertness and cognition
Mental status examination (MSE)
Appearance:
• Body type, posture, poise, clothes, grooming
• Anxiety (moist hands, perspiring forehead, tense posture and wide eyes).
Attitude
(towards the examiner )
• Cooperative, friendly, attentive, interested, frank, seductive, defensive, contemptuous,
perplexed, apathetic, hostile, playful, ingratiating, evasive or guarded
• Establishment of rapport?
Behaviour and psychomotor activity
• Unusual mannerisms - tics, gestures, twitches, stereotyped behaviour, echopraxia
(pathological imitation of movements), hyperactivity, agitation or restlessness,
combativeness, rigidity, agility, wringing of the hands, pacing, psychomotor retardation
(generalised slowing of movements which occurs in depressive states).
Mental status examination (MSE)
Speech:
• Rate (rapid, slow, halting)
• Amount /quantity (taciturn - untalkative, lacking spontaneity, grandiose)
• Tone (monotone, singsong, slurred)
• Speech impairment (dysarthria, echolalia, stuttering)
• Aphasia
Note - depressed patients tend to speak in a low monotone and may give
monosyllabic answers to questions. They also tend to avoid eye contact
Mental status examination (MSE)
Mood and Affect:
• Mood - emotion that colours the person’s perception of the world:
o Depth
o Intensity
o Duration
o Fluctuations
• Affect - present emotional responsiveness, inferred from facial expression:
o Normal (variation of facial expression, tone of voice, use of hands and body movements)
o Constricted - range and intensity reduced
o Blunted - further reduced.
o Flat - virtually no sign of affective expression (monotonous voice, immobile face )
Note people with depression have low mood, those with mania have elated or euphoric mood
Mental status examination (MSE)
Perception: involve the sensory nervous system. Need to look for:
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Hallucinations - false sensory nervous perception (any of the five) not associated with real
external stimuli
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Auditory hallucinations occur commonly in psychosis.
Visual hallucinations tend to occur in organic states
Bodily sensation (feeling) occur mainly in schizophrenia (& alcohol withdrawal).
Olfactory hallucinations found epilepsy, schizophrenia and other organic states;
Gustatory hallucinations can occur in schizophrenia (& alcohol withdrawal)
Illusions - misinterpretation of a real external sensory stimulus:
• e.g. the movement of the curtain as a person and become frightened.
• occur in schizophrenia but may also occur in delirium
3.
Depersonalisation and derealisation - These are alterations in an individual‘s perception of
reality.
• depersonalisation feels detached and view’s oneself as strange and unreal
• derealisation - Objects in the outside world may seem altered in size and shape, and people may
appear dead or mechanical
Mental status examination (MSE)
Thought Process (form of thinking) - the way in which a person puts together
ideas and associations (the flow, logic and associations):
• Loose associations - no logical connection – words make sense but sentence does not
• Circumstantiality – ‘overinclusion of trivia’ – loses the point
• Tangentiality – wanders off the subject with related words
• Thought blocking – thinking process stops and mind goes blank
• Perseveration – repetition out of context of same words & won’t stop
• Echolalia – direct repetition of examiner’s words
• Clang associations (punning) – associations by sound (rhyme) or (pun - double) meaning
• Neologisms – invention of new words by combining or condensing
• Word salad – incoherent connections of thought
• Flight of ideas - succession of associations move abruptly from idea to idea
Mental status examination (MSE)
Thought Content
• Delusions - fixed, false beliefs, based on incorrect inference about external
reality, not consistent with a patient’s intelligence and cultural background
and cannot be corrected by reasoning. Types of delusions include:
• persecution, morbid jealousy and infidelity, love, misidentification, grandiose, religious,
guilt and unworthiness, poverty, hypochondriacal, infestation and delusions of control
leading to passivity
• Obsessions - persistent intrusive thoughts, ideas and impulses that occur in
anxiety states:
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Preoccupations
Compulsions
Phobias
Plans, intentions
• Suicidal and homicidal thoughts (may need specific enquiry)
Mental status examination (MSE)
Alertness and Cognition
• Alertness (observed) –alert, in stupor or lethargic.
• Orientation - capacity of a person to gauge accurately time, place and person. Severity occurs in
increasing order from time, to place, and in person
• Attention and concentration - Attention refers to the objective observation of another person, object
or event. (use serial 7’s, 3’s, spelling backwards etc.
• Memory (immediate, recent, recent past, long term)
• Abstract thinking – ability to deal with concepts (comparison of objects, simple proverbs)
• Impulsivity – capability of controlling urges (sexual, aggressive, others..)
• Judgement - understanding likely outcome of behaviour
• Fund of knowledge – intellectual capability based on educational and cultural background
• Insight - degree of awareness about their own state
• Reliability – how honest, dependable
Further mental status physical examination
Stigmata that may lead panel physician to suspect use of psychoactive
drug by the applicant:
• characteristic dental discoloration of the teeth and the flattening of
the molars and premolars, that occurs with long-term use of khat,
betel nut
• blood-shot eyes, alcoholic facies (parotid enlargement/hypertrophy,
oedema, flushing).
• evidence of intravenous puncture-sites on the arms or legs in IV drug
users.
If identify or suspect should further investigate……
Mental Health – substance abuse detection
Psychiatric referral for further evaluations and/or
• Random drug screens (ideally three to four over a 12 month period)
– note applicant not aware of planned day.
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• On the day of planned drug screen, nurse calls the applicant first thing in the
morning and advise to present themselves to the clinic the same day for
evaluation.
• On arrival at the clinic, applicant asked to provide a urine sample (at least
10mls in a clear container).
• Anti-fraud measures should be observed to avoid applicant substitution and
the collection of the sample must be supervised. The provided sample –
warm, bubbly, condensation on the bottle
• For known IV drug users remember to do HIV, Hep B and Hep C tests
Mental Health – psychiatric/psychologist referral
Refer to a specialist consultant if after assessment unable to:
• Arrive at a probable diagnosis for purposes of the determination of a mental disorder with
associated harmful behaviour.
• Arrive at a probable diagnosis of a substance-related disorder.
• Arrive at a probable diagnosis for past episodes of mental disorder or determine that previous
difficulties in functioning were a result of a mental disorder.
• Rule out the presence of a mental disorder.
• Determine if harmful behaviour has been associated with a physical or mental disorder
• Determine if any associated harmful behaviour is likely to recur or under control.
• Determine the likelihood of maintaining remission or effective control of diagnosed physical or
mental disorders that affect behaviour.
Important information to clarify:
• What are the prospects for better prognosis with adequate treatment and care?
• Whether the applicant poses a danger to him/herself or to the public
Mental Health – travel concerns
Note while not the primary aim – consideration for travel may be required:
• fitness to travel – airline rules!!
• refugee applicants may need medical or other escort. Consider for following
conditions:
• Schizophrenia and other Schizophrenia Spectrum Disorders,
• Bipolar Mood Disorder,
• Major Depressive Disorder,
• Moderate to Severe Intellectual Disability Disorder,
• Anxiety Disorders, including PTSD, General Anxiety Disorder, Specific Phobias, Panic Attacks.
Aim for good stabilisation prior to travel.
• Quick Mental Status Examination (behaviour, mood, speech, perception, thoughts, cognition)
• Risk Assessment for disruptive behaviour i.e. agitation, violence, suicide, panic
• Quickly obtain corroborative/collateral information, if possible, from the family members, or
whoever is travelling with the migrant.
Questions