Download List of amendments in this update

Australian College of Rural & Remote Medicine
Rural Clinical Guidelines
MENTAL HEALTH
Australian College of Rural and Remote Medicine
Rural Clinical Guidelines
ACRRM – July 2012
Note: As these guidelines have been specifically designed to be used on a mobile/smartphone device
or as an online activity on https://www.rrmeo.com you will find that there are numerous hyperlinks that
you will not be able to access in this .pdf document.
To further enhance the usability of the guidelines this .pdf version now has hyperlinks ‘from and back
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As each discipline is a separate file it is suggested that you also download the ‘Alphabetical List’ of
the guidelines to enable easy cross reference to guidelines in other disciplines.
For a list of all the abbreviations used in these guidelines download the ‘Abbreviations List’.
Table of Contents
End-user licence agreement for ACRRM Mobile Device Clinical Guidelines ............................................................................ 3
List of amendments in this update ............................................................................................................................................. 4
RRMEO Modules ...................................................................................................................................................................... 5
ACUTE PSYCHOSIS ................................................................................................................................................................ 9
BEHAVIOURAL EMERGENCIES ........................................................................................................................................... 14
EATING DISORDERS ............................................................................................................................................................. 18
MENTAL STATE EXAMINATION ........................................................................................................................................... 22
SUICIDE RISK ASSESSMENT ............................................................................................................................................... 26
ACRRM Rural Clinical Guidelines – Mental Health – Version July 2012
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End-user licence agreement for ACRRM Mobile Device Clinical Guidelines
1. Introduction
(i) The terms and conditions stated here are in addition to the terms and conditions of the End-User
Licence Agreement for licensees of ACRRM software (Software Licence Agreement) which also apply
to your use of these Mobile Device Rural Clinical Guidelines (Guidelines).
2. Acknowledgement
(i) The Guidelines were developed by the Australian College of Rural and Remote Medicine (ACRRM).
3. Intellectual property rights
(i) The Software Licence Agreement is a legal agreement between the customer and ACRRM which
sets out the terms and conditions of this legal agreement. By clicking on 'Accept' and downloading the
Guidelines you have agreed to be bound by the terms and conditions of the Software Licence
Agreement.
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Guidelines may not be transmitted to or distributed to or used by other persons.
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commercialised without the prior written permission of ACRRM.
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new versions of the Guidelines become available however you are responsible for checking whether
you have the most recent version. The most recent version of the Guidelines is available on the
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arising from your failure to download updates of the Guidelines.
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(i) The Guidelines are intended to aid Permitted Users in the management of their patients but do not
provide explanations as to the conditions or treatments outlined. There may be clinical or other
reasons for using different therapy. In all cases, users should understand the individual situation and
exercise independent professional judgment when assessing therapy based on these Guidelines.
Users should seek independent advice.
(ii) The Guidelines do not include comprehensive drug information. Drug usage and doses should
always be checked prior to administering drugs to patients.
(iii) Every effort has been made to ensure the validity and accuracy of the information in this
adaptation of the Guidelines however Permitted Users should at all times exercise good clinical
judgment and seek professional advice where necessary. Treatment must be altered if not clinically
appropriate.
(iv) This adaptation of the Guidelines is presented as an information source only and provided solely
on the basis that users will be responsible for making their own assessment of the matters presented
herein. Users are advised to formally verify all relevant representations, statements and information
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ACRRM Rural Clinical Guidelines – Mental Health – Version July 2012
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MENTAL HEALTH
List of amendments in this update
No new amendments in this update
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ACRRM Rural Clinical Guidelines – Mental Health – Version July 2012
Page 4 of 28
MENTAL HEALTH
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RRMEO Modules
Note: This section of the 'ACRRM Clinical Guidelines' is for the sole purpose of assisting users to locate other
educational resources relevant to the ACRRM Curricula statements and to use them as a reference tool only.
You are again reminded that your knowledge acquisition must still be via the directives set out in each of the
ACRRM curricula statements.
This list of modules can be accessed via RRMEO
- to enrol go to RRMEO: https://www.rrmeo.com - Educational Inventory/RRMEO Modules
Note: Abbreviations used:
ATSI = Aboriginal and Torres Strait Islander Health
AIM = Adult Internal Medicine
Anaes = Anaesthesia (JCCA, advanced rural skills)
EM = Emergency Medicine
GEM = Generalist Emergency Medicine (GEM) (Post-Fellowship program)
MH = Mental Health
Obs = Obstetrics and Gynaecology (DRANZCOG Advanced)
Paeds = Paediatrics
Pop = Population Health
RM = Remote Medicine
Surg = Rural Generalist Surgery
Module Name
Suggested Curricula relevance
An Introduction to Digital Photography and Videography
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
Antenatal Care
ATSI
MH
Obs
RM
Best Care Guide to Stroke Management in General Practice:
Module 1
- Transient Ischaemic Attack (TIA) and Early Assessment
Module 2
- Antiplatelet Therapy for Secondary Stroke Prevention
Module 3
- Preventing Fatal and Disabling Stroke in Patients with Atrial Fibrillation
ATSI
AIM
EM
GEM
MH
RM
Breast Cancer
- How not to miss a breast cancer / the triple test in practice
Breast cancer diagnosis
- What now?
Breast cancer treatment
- Managing the impact
Breast cancer treatment is over
- What's next?
ATSI
AIM
EM
GEM
MH
Obs
RM
Surg
Education Program in Cancer Care
(EPICC)
Module 1A
- General Principles of Cancer Care
Module 1B
- Types of Cancer Treatment
ATSI
AIM
Anaes
EM
GEM
MH
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Module 1C
- Cancer Diagnosis
Module 1D
- Multidisciplinary Care Teams
Module 2
- Side Effects of Treatment and Symptom Management
Module 3
- Oncological Emergencies
Module 4
- Psychosocial Care
Module 5
- Follow Up
Obs
Paeds
RM
Surg
General Practitioners Guide to Parkinson's Disease
ATSI
AIM
EM
GEM
MH
Obs
Paeds
RM
Introduction to
Cultural Awareness
ATSI
Pop
RM
Introduction to
Dental Emergencies
ATSI
Anaes
EM
GEM
Paeds
RM
Surg
Introduction to
Population Health
ATSI
EM
GEM
MH
Obs
Paeds
Pop
RM
Mx of Autism Spectrum Disorders in Childhood and Adolescence
Module 1
- Clinical Aspects and Diagnosis
Module 2
- Treatment and Ongoing Management
Module 3
- Special Challenges
ATSI
Paeds
RM
Mx of
Secondary Lymphoedema
ATSI
AIM
Paeds
RM
Surg
Non-Directive Pregnancy Support Counselling Training
ATSI
Obs
RM
Opioid Medication in Palliative Care
ATSI
AIM
Anaes
EM
GEM
MH
Paeds
RM
Surg
Palliative Care
- Choose Your Own Adventure
ATSI
AIM
MH
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Paeds
RM
Palliative Care in
Aged Care Homes
- Palliative Care Australia
ATSI
AIM
MH
RM
Radiology Online
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
RM
Surg
RANZCP - IMG Orientation
Module 01
- Components of Australian health care
Module 02
- Subspecialties of psychiatry
Module 03
- Professional expectations, your responsibilities & rights
Module 04
- Patient & community expectations
Module 05
- Mental health care in a multicultural community
Module 06
- Aboriginal & Torres Strait Islander mental health care
Module 07
- Gender & sexuality
Module 08
- Mental health in rural & remote Australia
Module 09
- Funding & payments
Module 10
- Mental health legislation & regulation
Module 11
- Psychiatric treatment in Australia
Module 12
- Current issues in mental health policy & Australian psychiatry
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
Renal Failure
ATSI
AIM
Anaes
EM
GEM
Paeds
RM
Surg
Retrieval Medicine
- Advanced
- Basic
ATSI
AIM
Anaes
EM
GEM
MH
Obs
Paeds
Pop
RM
Surg
RVTS
Mental Health Disorders Package
for
Rural Practice Core
ATSI
AIM
EM
GEM
MH
Paeds
Pop
RM
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Sexual Health
- taking a sexual history and managing STI's
ATSI
AIM
EM
GEM
MH
Obs
RM
Tele-Derm National
ATSI
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
Tele-Tox
ATSI
AIM
Anaes
EM
GEM
Obs
Paeds
Pop
RM
Surg
The Beginnings of
Practice Management
RM
Women's Health
- Contraceptive Options in the Bush
ATSI
Obs
RM
(Back to Top)
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Page 8 of 28
MENTAL HEALTH
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ACUTE PSYCHOSIS
(see also in Emergency Med.)
Aims
Dx:
- Clinical
- Risk
Tx:
- Behavioural Emergencies
- Acute
- Chronic
AIMS
Risk Assessment
- patient (self harm, suicide)
- others (aggression, violence)
Early recognition of psychosis
- may prevent full blown Sx and Cx
- Prodromal Sx - see Notes (1) - Prodromal symptoms of psychosis
DX:
1. Clinical
Thorough Mental State Examination
Use full set of questions in Notes (2) - Questions designed to elicit some symptoms of psychosis
Symptoms
- see Notes (3) - Symptoms of psychosis
Causes
- see Notes (4) - Causes of acute psychosis
IF
- drowsy, disoriented, cognitive deficit
--> Consider secondary (physical) causes
IF
- elevated or irritable affect
- psychomotor agitation and acceleration
- pressure of speech / flight of ideas
- delusions of grandeur / hallucinations
-->Consider Bipolar disorder
IF
- depressive symptoms / hallucinations
- mood congruent delusions (guilt, poverty, nihilism)
--> Consider psychotic depression
IF
- prominent mood symptoms PLUS
- positive / negative / cognitive Sx
--> Consider schizoaffective disorder
IF
- No prominent mood symptoms
--> Consider schizophrenia
N.B.
Debate about the presence of a mental illness or the diagnosis of schizophrenia is likely to be entirely
counterproductive in the insightless patient.
Physical Assessment
As possible - may need to be deferred until psychosis controlled
esp. Neurological exam
Ix:
Baseline - exclude organic causes
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FBC
U&E's, Blood sugar
CRP / ESR
TFT
Ca2+
B12 / folate levels
Urinary drug screen
HIV if appropriate
CT brain
EEG if temporal lobe epilepsy suspected
2. Risk Assessment
Risks:
- suicide / self harm
- physical harm to others
- accidental mishap eg. wandering, dehydration
- vulnerability eg. sexual exploitation
- disinhibition eg. financial
- self care esp. medical disorder
Increased Risk:
Static
- younger
- male gender
- unemployment
- homeless / instable living
- previous forensic Hx
- PHx suicide attempts / violence
Clinical
- command auditory hallucinations
- thought broadcasting
- persecutory delusions
- lack of insight
- hopelessness
- suspiciousness, hostility, irritability
Situational
- access to weapons
- lack of support
- intoxication
TX:
1. Behavioural Emergencies
2. Acute Symptoms
Use familiar drugs
Seek advice if inexperienced
Titrate dose to patient
Oral Tx preferred
Monitor Vital Signs, O2 sats for 4 hrs post Tx
Record all doses & times
--> copy to travel with patient at all times
ORAL
(i) BENZODIAZEPINES
Beware
- paradoxical reactions (reversible with Flumazenil)
- addiction in long term
Healthy young male may need
- 10-20mg diazepam QID orally
(ii) ANTIPSYCHOTICS
Chlorpromazine 50-200 mg orally (up to 400 mg daily)
- - beware postural hypotension (nurse in bed)
- additive sedation if used with benzodiazepines
- avoid use in elderly, delirium
Olanzapine
- 10-20mg orally, repeat 2-4 hrs
Quetiapine
- 50-100mg up to QID
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PARENTAL
(i) MIDAZOLAM = preferred first line
- 2.5(elderly, frail) --> 10 mg (young, large)
- IM effect in 3 mins --> repeat 10 minutely
- IV effect in 1 min --> repeat 5 minutely
- antidote FLUMAZENIL 0.2-0.3 mg slow IV over 15 sec
(ii) DROPERIDOL / OLANZAPINE
- 5-10 mg IM
- beware dystonic reactions --> Benztropine
3. Transport
- must have constant supervision, monitoring of vital signs, resuscitation equipment available and a capacity to
respond to deterioration of patient
- allow for delays & provide for repeat medications
4. Chronic Mx
Pharmacological:
Psychotic Sx
- antipsychotics
Mood disorders
- stabilizers (lithium, valproate)
- antidepressants
- ECT
Psychosocial:
- GP
- Mental Health Services
- psychiatrist
- psychotherapy
Family:
- support
- psychotherapy
- education
- resources
eg.
-- Mental Illness Fellowship
-- ARAFEMI = Association of Relatives and Friends of the Emotionally and Mentally ill
-- SANE Australia (www.sane.org)
-- The Royal Australian and New Zealand College of Psychiatrists (www.ranzcp.org)
NOTES
1. Prodromal symptoms of psychosis
2. Questions designed to elicit some symptoms of psychosis
3. Symptoms of psychosis
4. Causes of acute psychosis
1. Prodromal symptoms of psychosis
- Reduced concentration, attention
- Deterioration In role functioning
- Irritability
- Suspiciousness
- Reduced drive and motivation, anergia
- Anxiety
- Social withdrawal
- Sleep disturbance
- Depressed mood
2. Questions designed to elicit some symptoms of psychosis
Auditory hallucinations
- Do you hear voices of people talking to you even when there is no one around?
Thought insertion
- Have you felt that thoughts are being put into your mind? Do you experience telepathy or extra sensory
perception?
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Thought withdrawal
- Have you experienced thoughts being taken out of your mind?
Thought broadcasting
- Have you felt that other people know what you are thinking?
Thought echo
- Can you hear your thoughts spoken aloud?
Delusion of control
- Have you felt the control or influence of an outside force?
Delusions of reference
- Do programs on the television or radio hold special meaning for you?
Delusions of persecution
- Do you feel that you are being singled out or picked on? Is there a conspiracy against you?
Delusions of grandeur
- Do you have special abilities or power?
Delusions of guilt
- Do you believe that you have ever done something deserving punishment?
Depressed mood
- Have you been feeling sad or down in the dumps recently, not enjoying activities as much as before?
Elevated mood
- Have you been feeling particularly good in yourself, more cheerful, full of life?
3. Symptoms of psychosis
Positive symptoms
- Delusions and hallucinations
- Formal thought disorder
Negative symptoms
- Flat affect
- Poverty of thought
- Lack of motivation
- Social withdrawal
Cognitive symptoms
- Distractibility
- Impaired working memory
- Impaired executive function
Mood symptoms
- Depression
- Elevation (mania)
- Mixed affective state
Anxiety/panic disorder
Aggression/hostility/suicidal behaviour
4. Causes of acute psychosis
Illnesses (primary causes)
- Schizophrenia (including schizophreniform disorder)
- Schizoaffective disorder
- Bipolar mania and mixed affective states
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- Major depression
- Delusional disorder (paranoid psychosis)
Physical causes (secondary causes)
Medications and substances
- Amphetamine, stimulant, hallucinogen or cannabis use
- Corticosteroid treatment
- Alcohol intake
CNS pathology
- Cerebral trauma
- Cerebral tumour
- Cerebrovascular disease
- Temporal lobe epilepsy
- CNS infections - e.g. HIV infection
- Huntington's disease
- Dementias
- Inflammatory conditions
e.g. systemic lupus erythematosus
- Demyelinating conditions
e.g. multiple sclerosis
Endocrine disorders
- Cushing's disease
- Thyrotoxicosis
- Hyperparathyroidism
Vitamin and toxic disorders
- Vitamin B group deficiencies
- Wilson's disease
- Heavy metal poisoning
References:
Management of Acute Psychosis - J. Hope, N Keks
Medicine Today 4/2008 vol9, no4
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ACRRM Clinical Guidelines Version July 2012
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Page 13 of 28
MENTAL HEALTH
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BEHAVIOURAL EMERGENCIES
(see also in EM)
Aims
Dx
Tx
Drugs
Transportation
AIMS
Legal obligations
Safety
Family & friends
Legal Obligations
Tx without consent options:
(i) Meets criteria for involuntary psychiatric Tx (be aware of criteria)
(ii) Common Law principle of ‘Duty of Care’
- use professional guidelines / good clinical judgment
- consider ‘No intervention’ Vs ‘Treatment’
- consult senior colleague if possible
- keep meticulous records
Safety
Beware community settings unless sufficient support
- police / ambulance / mental health team
Principles
Privacy
Room
- 2 exits
- no weapons eg. furniture
Duress alarm
Consider weapons
- equipment
- personal belongings eg. stethoscope around neck
Beware hidden weapons on patient
Patient
- keep safe distance
-keep in vision always
Family & Friends
- reassure
- arrange follow up / debrief
Dx
Often unknown / provisional
3 main groups
- often mixed aetiology
(i) Medical
- usually with delirium
(ii) Substance intoxication / withdrawal
(iii) Psychiatric
IF no medical / psychiatric cause
--> police intervention without medical involvement may be appropriate
Tx
DE-ESCALATION
(i) VERBAL
Be calm, confident, empathetic but businesslike
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Avoid
- sudden movements
- encroaching patients personal space
- prolonged eye contact
- confrontation
Introduce yourself
- use your name & patients name (personalise interaction)
- explain your role (to assess, help)
Support
- offer food, water
- physical needs eg. toilet
- other eg. telephone, family contact
Assess responsiveness to verbal de-escalation
- immediacy of danger
- likelihood of psychotic Sx
Medical assessment:
Mental Status Examination
Physical: (minimum)
- visual assessment
- vital signs / 02 sats
Ix:
- blood sugar
-urinalysis / toxicology
Attempt:
- negotiation
-co-operation esp. to medications
(ii) SHOW OF FORCE
IF verbal de-escalation impossible, ineffective
(ie. have sufficient staff visibly backing up clinician while negotiating)
(iii) PHYSICAL RESTRAINT
ONLY IF
- persistent / recurrent behavioural emergency
- escalating aggression, distress, violence
AIM
- minimise ability of patient to move or injure themselves
- ensure patient airway & circulation not obstructed
- to safely give medication
NB
- requires a trained team following a set protocol
(usually 6 members - 1 for each limb, head, to give injection)
- Ad hoc groups of people without training may result in injury
DRUGS
IV Route
IM Route
Psychostimulant Intoxication
(i) MONITORING
Vital signs
Pulse Oximetry
ECG if antipsychotics given parenterally
OBSERVE FOR
a) Over sedation / respiratory depression
- ABC
- Flumazenil - if benzodiazepine induced
dose 0.2 mg IV followed by 0.1 mg every minute (max 1 mg)
N.B.
- may cause withdrawal seizures if chronic Tx
- ½ life 1 hr --> may wear off before diazepam (recurrence of Sx)
b) Extrapyramidal Sx (up to 48 hrs)
- Benztropine 1-2 mg orally or IM
2) ACUTE MEDICAL SETTINGS
AIM
- Sedation = a state of rousable drowsiness
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IV ROUTE (preferred option)
(i) Diazepam OR Midazolam
2.5-5 mg IV every 3-4 mins until desired effect
Seek senior advice if > 20 mg needed
AND / OR
(ii) Droperidol 5-10 mg IV
onset of action 10-20 mins
esp. if tolerance to benzodiazepines
N.B.
- assoc. with Long Q-T Interval
- use ECG monitoring if possible
- usually has occurred after prolonged high oral dosage
Avoid / Beware
- older patients
- medically ill
- if other medications assoc with Long QT
- if no previous antipsychotic drug Tx
N.B.
- do not combine Diazepam & Droperidol in same syringe
- Haloperidol NOT RECOMMENDED b/c high risk of cardiac arrhythmia & sudden death after IV administration
IM ROUTE
(i) Midazolam 10-15 mg IM
Continue physical restraint until effective
Doses less than 10 mg not effective in adults
Establish IV access ASAP
(ii) Droperidol 5 mg IM
IF failure with midazolam or known benzodiazepine tolerance
N.B.
- see warning above
PSYCHOSTIMULANT INTOXICATION
ie. amphetamines, cocaine, ecstasy
IF Oral Tx possible
--> Diazepam 10-20 mg
then 10 mg every 30 mins until effect (max 60 mg)
IV --> Diazepam
2.5-5 mg IV initial dose
IF no response at 10 minutes give 2.5-10 mg at 10 minute intervals until adequate sedation (max 60 mg)
IF no response
--> Droperidol 2.5-5 mg repeated every 20 mins (max 20 mg)
N.B.
- see warnings above
IM - IF oral / IV routes not available
--> Midazolam 5 mg IM
IF no response 10 mins give 10 mg IM
Repeat ONCE after 10 minutes if needed
--> No response --> Droperidol 5 mg IM
N.B.
- see warnings above
NB
- BEWARE life-threatening hyperthermia
IF febrile after sedation --> reduce body temp & seek advice
TRANSPORTATION
CONSIDER
Mental health regulation, legislation
- patient consent may be withdrawn during transport
Type of transport, duration, possibility of delay
- medication required
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- pressure care
- restraint
- IV lines (preferably 2 if req'd)
IF medicated
- monitoring, resuscitation equipment
- appropriate escorts (nurse, ambulance, police, other)
- requires ambulance, NOT police car
Family reassurance, support
REMEMBER
Occasionally necessary to anaesthetise for transport
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Page 17 of 28
MENTAL HEALTH
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EATING DISORDERS
Aims
Dx
DDx
Sx
O/E
Ix
Tx
Notes
AIMS
3rd most common chronic illness in adolescent females
(after asthma, obesity)
Anorexia Nervosa (AN)
- pathological fear of weight gain plus overwhelming drive for thinness
Bulimia nervosa (BN)
- recurrent (twice weekly for 3 months) episodes of binge eating and inappropriate compensatory behaviours
EDNOS (Eating Disorders not otherwise specified)
- i.e. criteria for AN or BN not fully met
- higher incidence than AN or BN
- may be as serious as AN/BN
Dieting is a major risk factor
Early warning signs:
- constant focus on diet, food, exercise
- insisting on different meals from rest of family
- feeling stressed when unable to exercise
- frequent weighing
- frequent visits to bathroom after meals
Dx:
DSM-IV Diagnostic criteria --> See Notes
Presentations:
Concerned parents / school nurse / counselor
Altered eating behaviour
Excessive exercise
Amenorrhoea (3 consecutive cycles)
Depression
Social withdrawal
Physical Sx:
- under nutrition (dizziness, fatigue, headache)
- abdominal (nausea, vomiting, bloating, constipation)
DDx:
Beware - Dx may be missed in pursuit of Ix
Inflammatory Bowel Disease
Coeliac Disease
Diabetes Mellitus
Hyperthyroidism
Malignancy
- CNS / lymphoma / leukaemia
Psychiatric
- depression
- anxiety disorder
- obsessive compulsive disorder
Addison's disease
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Sx:
Questions:
- How do you feel about your weight?
- How much do you think you should weigh?
- Have there been any concerns about your eating / exercise behaviours?
- Amenorrhoea?
O/E:
May be normal
(i) Anorexia Nervosa
- growth / pubertal delay
- cachexia / sallow complexion
- dry hair / skin
- vitals
-- hypothermia / bradycardia / postural hypotension / tachycardia
- reduces muscle bulk / subcutaneous tissue
- ankle oedema
(ii) Bulimia Nervosa
- normal or overweight
- dental erosion
- parotid enlargement
(iii) Weight
- height, weight, BMI
- plot on centile charts
= 24 hr dietary record
NB.
- weight may be normal in BN
- failure to gain weight appropriately may be presentation
(rather than weight loss)
(iv) Mental State Examination
Ix:
- FBC
- urea / electrolytes
- BSL
- calcium / Mg / Po4
- LFT's
- FSH, LH, oestradiol (usually low)
- bone densitometry (monitor yearly)
- Vitamin D
- B12 / folate / iron studies
- TFT's
Consider:
- ECG if arrhythmia
- Ix for coeliac / IBD
Tx:
Numerous approaches, poor evidence base
Admission Criteria
AN - stable medically
Bulimia Nervosa
(i) Admission Criteria
- bradycardia < 50bpm
- postural hypotension
( > 10mmHg syst.)
- hypothermia
( <35.5oC)
- arrhythmia
- severe electrolyte disturbance
- suicidal idealation
- growth failure in young adolescents
Beware:
- rapid weight loss
(increased risk)
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(ii) AN - stable medically
Specialist multidisciplinary outpatient Tx
- medical, nutritional, mental health
Family Based Therapy (FBT)
- family actively involved
- typically 6-12 months
Individual therapy
eg. CBT, psychotherapy, nutritional counselling
- only recommended after weight restoration achieved
(iii) Bulimia Nervosa
Cognitive Behavioural Therapy (CBT)
- aims to normalise eating patterns and reduce binge / purge episodes
Interpersonal Therapies
- psychotherapy, FBT
NOTES:
Eating Disorder Diagnostic Criteria from DSM IV-TR
- Anorexia Nervosa
- Bulimia Nervosa
- EDNOS
1. ANOREXIA NERVOSA (307.1)
(i) Refusal to maintain body weight at or above a minimally normal weight for age and height
(e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make
expected weight gain during period of growth, leading to body weight less than 85% of that expected).
(ii) Intense fear of gaining weight or becoming fat, even though underweight.
(iii) Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or
shape on self-evaluation, or denial of the seriousness of the current low body weight.
(iv) In postmenarcheal females, Amenorrhoea,
(i.e. the absence of at least three consecutive menstrual cycles)
(a woman is considered to have Amenorrhoea if her periods occur only following hormone, e.g. estrogen,
administration)
Type:
(i) Restricting
- during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging
behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
(ii) Binge-Eating/Purging
- during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging
behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
2. BULIMIA NERVOSA (307.51)
(i) Recurrent episodes of binge eating characterised by both:
- eating, in a discrete period of time (e.g. within any 2-hour period) an amount of food that is definitely larger than
most people would eat during a similar period of time and under similar circumstances
- a sense of lack of control over eating during the episode (such as a feeling that one cannot stop eating or control
what or how much one is eating)
(ii) Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting or excessive exercise.
(iii) The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week
for 3 months.
(iv) Self-evaluation is unduly influenced by body shape and weight.
(v) The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Type:
(i) Purging
- during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas
(ii) Nonpurging
- during the current episode of Bulimia Nervosa, the personas used other inappropriate compensatory behaviours,
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such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of
laxatives, diuretics, or enemas.
3. EATING DISORDER NOT OTHERWISE SPECIFIED (307.50)
This diagnosis includes disorders of eating that do not meet the criteria for the previous two eating disorder
diagnoses.
Examples include:
(i) For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.
(ii) All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's
current weight is in the normal range.
(iii) All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory
mechanisms occur less than twice a week or for less than 3 months.
(iv) The patient has normal body weight and regularly uses inappropriate compensatory behaviour after eating
small amounts of food (e.g. self-induced vomiting after the consumption of two cookies).
(v) The patient engages in repeatedly chewing and spitting out, but not swallowing, large amounts of food.
(vi) Binge-eating disorder: recurrent episodes of binge eating in the absence of regular inappropriate
compensatory behaviour characteristic of Bulimia Nervosa.
Listed in the DSM IV-TR appendix as a diagnosis for further study:
Binge Eating Disorder is defined as uncontrolled binge eating without emesis or laxative abuse.
- it is often, but not always, associated with obesity symptoms.
Night eating syndrome includes morning anorexia, increased appetite in the evening, and insomnia.
- these patients can have complete or partial amnesia for eating during the night.
Reference:
Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed,
text rev. Washington, DC, American Psychiatric Association, 2000.
RESOURCES:
1. Eating Disorders Victoria http://www.eatingdisorders.org.au
2. Eating Disorders Queensland http://www.eda.org.au
REFERENCES:
DSM IV-TR Diagnostic
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MENTAL HEALTH
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MENTAL STATE EXAMINATION
(see also in Emergency Medicine)
Aim
Appearance
Behaviour
Speech
Mood
Affect
Perception
Thought
Cognition
Notes
AIM
Essential part of any psychotic assessment
APPEARANCE
- self care
- grooming
- general physical health
- dress
(see Notes 1. Appearance)
BEHAVIOUR eg.
- psychomotor agitation / retardation (depression)
- tremor / sweats
- anxiety / startle
- akathisia / parkinsonism (antipsychotics Tx SE)
- catatonia
SPEECH
- volume, rate
- command of grammar / vocabulary
- dysphasia (eg. CVA)
(see Notes 2. Speech)
MOOD = sustained emotional tone reported by individual
eg.
- euthymic
- depressed
- angry
- elated
- elevated
- irritable
- anxious
AFFECT = emotional response witnessed during interview
eg.
- appropriate / inappropriate
- fatuous/ blunted / restricted / flat / labile
PERCEPTION - (see Notes 3. Hallucinations )
Hallucinations:
- visual, gustatory, olfactory, kinaesthetic, auditory
Illusions:
- usually organic Sx
eg.
- intoxication, delirious
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THOUGHT
Form:
- loosening of association
- incoherence
- concrete thinking
Content:
- delusions = psychotic illness
eg. persecutory, grandiose, nihilistic, bizarre
- overvalued ideas
eg. hypochondriasis
- phobias, obsessions, compulsions
eg. anxiety, OCD
Possession:
- Sx of schizophrenia
- thought insertion, withdrawal, broadcast, block
- passivity phenomena
Stream:
- flight of ideas (eg. mania)
- psychomotor retardation (depression)
- circumstantial (eg. personality, organic disorders)
COGNITION - (see Notes 4. Cognition)
Level of consciousness:
- alert, clouded, comatose
Orientation:
- person, place, time
Attention: eg
- serial 7's or 3's
- spell 'WORLD' backwards
- recite months backwards
Memory:
- immediate (3 object recall)
- short term (recall after 5 mins)
- long term (past world events)
General knowledge:
- current world events
Abstract thinking:
- proverb interpretation
- differences (eg. dwarf - child)
Judgment:
- informal (during interview)
- 'what would you do if you found a stamped addressed envelope'
Intelligence:
- informal assessment
- neuropsychological assessment
Mini-Mental test (see Notes 5. MMSE)
= good screen
NOTES
Appearance
Speech
Hallucinations
Cognition
Mini Mental State Examination
1. Appearance
eg.
Depression:
- neglected self care
Schizophrenia:
- bizarre dress
- OCD
- excess conformity
2. Speech
eg.
Depression:
- electively mute
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Mania:
- pressure of speech
SCZ:
- poverty, lack of spontaneous speech
Intellectual disability:
- limited speech, vocabulary
3. Hallucinations
SCZ:
- auditory hallucinations most common
- may experience hallucinations in any modality
Delusional disorder:
- may have kinaesthetic or olfactory hallucinations related to delusional theme
4. Cognition
N.B.
Acute Brain syndrome: (delirium)
- rapid onset of Sx
- altered level of consciousness
- impaired attention and concentration
Chronic Brain syndrome: (eg. dementia)
- insidious onset of Sx
- normal level of consciousness
- memory and cognitive deficits common
- may have changed personality
Insight
- rarely 'all or none'
- depends on
--> condition person suffers
--> treatments available
5. Mini Mental State Examination
Orientation
What is the: Year? Season? Date? Day? Month?
Where are we: State? City? Suburb? Hospital? Floor/ward?
Registration
Name three objects, 1 second to say each.
Then ask the patient to repeat all three names after you have said them. (Give one point for each correct answer)
Repeat until the patient learns all three.
Count trials and record.
Trials =
Attention and Calculation
- Serial 7's. (1 point for each correct) Stop after five answers
Alternatively, have patient spell 'WORLD' backwards.
Recall
- Ask for the names of the three objects repeated in question above (1 point for each correct answer)
Language
- Name a pencil and a watch (2 points)
- Repeat following: "No ifs, ands or buts" (1 point)
- Follow a three-stage command: "Take a paper in your hand. Fold the paper in half. Put the paper on the floor."
(3 points)
- Read and obey the following: "CLOSE YOUR EYES." (1 point)
- Write a sentence (1 point)
- Copy a design (1 point)
Total score:.............(maximum score = 30)
Assess level of consciousness along a continuum:
- alert
- drowsy
- stupor
- coma
Reference:
A Manual of Mental Health Care in General Practice - John Davies 2003
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MENTAL HEALTH
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SUICIDE RISK ASSESSMENT
(also in Palliative Care)
Aims
Risk Assessment
Tx
AIMS:
True Emergency-life threatening situation
Clinical Judgement & effectively engaging patient is mainstay of quality care
Involve Mental Health Team if possible
Up to 10% commit suicide in 10yrs - esp in 1st yr
Major Risk
- 1st week post discharge
- close follow-up essential
RISK ASSESMENT:
Comprehensive Assessment requires
- regular reassessment
(not complete until cognitive function normal
esp post OD or OH ingestion)
- physical health assessment
- mental health assessment
(see Mental State Examination)
- psycho-social assessment
carers / family should be contacted & involved
IMMEDIATE GOALS
(i) Hospitalizations
- High risk
- Psychiatric disorder
(ii) Voluntary/involuntary patient
INCREASED RISK
Psychiatric illness
- severe anxiety/panic/depression
Demographic
-M>F
- age >55 or youth
- small community
- indigenous ethnicity
Alcohol/substance abuse
PHx suicide attempts
Social situation
- lack of resources/supports
- in custody
State of mind
- emotional hopelessness/helplessness
- self absorption
Sexual identity conflicts
LETHALITY
Document IPMO
- Intention
- Plan
- Motivation
- Opportunity
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Violent methods
= increased risk
(eg. recent purchase of firearm)
IF IN DOUBT
- ensure patient safety
- consult more experienced colleague
Tx:
High Risk
- hospitalise
- involuntary if non cooperative
Treat underlying mental illness
Resolve crisis
Reassess Regularly
- until cognition becomes normal
- before change in observation / setting
- change of Sx / presentation
INPATIENT SUICIDE - CAUSES
Inadequate
- security
- assessment
- reassessment
- communication btn staff
- care planning
Infrequent patient observation
Unavailable information
DISCHARGE CRITERIA
1. Acute problems identified, addressed, resolved
2. Person no longer feels suicidal
3. You believe person is no longer suicidal
4. Person agrees to seek help if suicidal ideas recur
5. Person not intoxicated, delirious, demented, psychotic
6. Person does not have access to lethal means
eg firearms, medication
7. Follow-up arrangements documented including 24hr phone no & name of an appropriate contact person
- copy given to patient/supports
8. Family/supports agree with discharge plan
9. Tx arranged for psychiatric problems
IF UNCERTAIN
- consult senior colleague
SUICIDE PREVENTION CONTRACTS
Dependant on
- patients competency to provide informed consent
- established clinician / patient relationship
(ie. not recommended)
- in emergency setting
- unknown patients
FOLLOW-UP
Continuity of therapist improves outcome
Document responsibility in the event of failure of arrangements
(must contact patient)
REFERENCES
1. Guidelines for the management of patients with suicidal behaviour or risk
- Queensland Health
2. The Emergency Medicine Manual 3rd ed 2003
- Venom publishing
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ACRRM Clinical Guidelines Version July 2012
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