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Psychotic disorder Edward LauWhat are these sessions intended to cover? • Focusing on key psychiatric differentials their • Symptoms • Management • Mental Health ActsLearning Objectives • To diagnose X condition based on holistic reasoning • To manage X condition • To understand and apply forensic sections of the Mental Health Act MENTAL HEALTH TRIBUNAL REPORT ON AK • Introduction • AK was transferred to X hospital from Prison Y on 24/04/21 and is detained on a hospital transfer with restrictionsunder Section 47/49. He was sentenced to 16 months of imprisonment at Z Court on 21/06/20 and the expiry of his sentence for the purposes of Section 50 is on the 21/10/21. He will then be detained on a Notional Section 37 of the Act. • Index offence • It is recorded that AK was walking down the street with his partner and was approached by a group of three men, during which the victim exchanged pleasantries with the passing female, unaware she was with AK. AK smashedthe victim in the face index offence was described as impulsive.njuries. TheMental Health Act 1983, amended 2007 •Mental Health Act 1983 amended ine 2007 • Do they have a mental disorder? AND • Is their physical health at risk? OR • Do they place themselves, or others in danger? AND • Appropriate resources are available • Mental disorder – any disorder or disability of the mind • Broad definition • Must consider Nature or Degree (either of which must justify the decision to section someone) Civil Sections of the Mental Health Act • Section 2 – 28 days for assessment • Section 3 – 6 months for treatment • Requires AMPH (Approved Mental Health Professional) to make application, and 2 Approved Clinicians (under section 12) to recommend. • Emergency sections – 72 hours • Section 4 – quicker version of section 2 • Section 136 – police to remove someone from public area • Section 135 – police with a warrant from the Magistrate to remove someone from private area • Section 5(2) – for patients already in hospital (but not A&E) • CTO • Patients may be placed on CTO following detention in hospital by RC with agreement with AMPH • For those who can now be cared for in community • They may be recalled back to hospital for further treatment or if they do not comply to conditions of CTO and detained for 72 hours from which further assessment is madeDifferent types of Criminal Courts • Crown Court • Holds trials for more serious crime offences and appeals from the magistrates’ courts • Most will be conducted with a jury • Magistrates Court • Deals with majority of criminal cases – summary offences • Youth Court • Deals with cases involving juveniles (< 18 years) except homicide Forensic Sections of the Mental Health Act • Section 35 – criminal courts to remand person to hospital for assessment (12 weeks), can be renewed • Section 36 – criminal courts to remand person to hospital for treatment (12 weeks) • Section 37 – Crown Courts to impose hospital order of convicted or found responsible person for an offence (manslaughter or on the grounds of diminished responsibility) • Section 38 – an interim hospital order for a convicted or found responsible person • Section 41 – restriction order • Section 45a – a Hospital order alongside a prison sentence, transferred back to prison afterwards to serve remainder of sentence • Section 47 – transfer direction for the sentenced • Section 48 – transfer direction for those on remand • Section 49 – restricted transfer direction for the sentenced • Section 50 – remove a patient from hospital back to prison to continue their sentence MENTAL HEALTH TRIBUNAL REPORT ON AK • Introduction • AK was transferred to X hospital from Prison Y on 24/04/21 and is detained on a hospital transfer with restrictionsunder Section 47/49. He was sentenced to 16 months of imprisonment at Z Court on 21/06/20 and the expiry of his sentence for the purposes of Section 50 is on the 21/10/21. He will then be detained on a Notional Section 37 of the Act. • Index offence • It is recorded that AK was walking down the street with his partner and was approached by a group of three men, during which the victim exchanged pleasantries with the passing female, unaware she was with AK. AK smashedthe victim in the face index offence was described as impulsive.njuries. The MENT AL HEAL TH TRIBUNAL REPORT ON AK • when he was younger. His mother is from France, but has spent the majority of her life in the UK. His parents divorced when he was 8 years old and he is the eldest of four children born to his parents, two sisters and one brother. His sister was admitted to a Mental Health Institution under the Mental Health Act 1983 due to a depressive episode of Bipolar when she was 21. Aside from this, there are no other family history of mental disorder, and no criminality. • It was however reported, that he chose to live with his father after his parents separated, and his father later remarried to a woman with a son older than AK at the time. • There were reports of sexual and physical abuse committed by his father and his step brother at the time. At school, he was reported to constantly get involved in fights, resulting in him changing schools numerous times. • He left school with no qualifications and left home at the age of 16, following which it has been reported that he became estranged from his family. He had little support and at times was homeless and lived rough, but had never found difficulty finding employment in manual jobs poor social network, but with several girlfriends, and has never married, with no children. a job for more then 6 months. He has reported a MENT AL HEAL TH TRIBUNAL REPORT ON AK • when he was younger. His mother is from France, but has spent the majority of her life in the UK. His parents divorced when he was 8 years old and he is the eldest of four children born to his parents, two sisters and one brother. His sister was admitted to a Mental Health Institution under the Mental Health Act 1983 due to a depressive episode of Bipolar when she was 21. Aside from this, there are no other family history of mental disorder, and no criminality. • It was however reported, that he chose to live with his father after his parents separated, and his father later remarried to a woman with a son older than AK at the time. • There were reports of sexual and physical abuse committed by his father and his step brother at the time. At school, he was reported to constantly get involved in fights, resulting in him changing schools numerous times. There were also reports of them moving house frequently. • He left school with no qualifications and left home at the age of 16, following which it has been reported that he became estranged from his family. He had little support and at times was homeless and lived rough, but had never found difficulty finding employment in manual jobs poor social network, but with several girlfriends, and has never married, with no children. a job for more then 6 months. He has reported a WHA T IS THE WORKING DIAGNOSIS AND WHA T ARE THE NEXT STEPS IF HE WAS ADMITTED DIRECTL Y UNDER S37? • AK reported that his father was from Ireland. There is no other detail available about his father, although it appeared that he lived with him and he is the eldest of four children born to his parents, two sisters and one brother. His sister was admitted to a Mental Health Institution under the Mental Health Act 1983 due to a depressive episode of Bipolar when she was 21. Aside from this, there are no other family history of mental disorder, and no criminality. • AK was born on March 1973 in Reading. There are no details available his mother’s pregnancy, his birth, early development or early childhood. older than AK at the time.hat he chose to live with his father after his parents separated, and his father later remarried to a woman with a son • constantly get involved in fights, resulting in him changing schools numerous times. There were also reports of them moving house frequently. • He left school with no qualifications and left home at the age of 16, following which it has been reported that he became estranged from his family. He had little support and at times was homeless and lived rough, but had never found difficulty finding employment in manual jobs poor social network, but with several girlfriends, and has never married, with no children. a job for more then 6 months. He has reported aNext Steps • Full history from patient, gain collaterals from staff, family, previous notes • MSE • Physical Examination • Psychological input long term • Further investigations • Routine bloods – FBC, LFTs, TFTs • CT/MRI head • HIV and syphilis screen • Urine drug test • Start on Medication • 3 Months • T2/T3 T2 T3 – requires SOAD • Diazepam • Haloperidol • Lorazepam • Aripiprazole • Procyclidine • Quetiapine • Tetrabenazine T2 and T3 • Haloperidol • Aripiprazole • Quetiapine • Diazepam • Lorazepam Excluded • Procyclidine • Senna • Senna • Chloramphenicol • Chloramphenicol • Tetrabenazine http://www.oxfordhealthformulary.nhs.uk/docs/Vol%2014t%20Feb%202016.pdfnes%20and%20the%20Mental%20Health%20Ac MENT AL HEALTH TRIBUNAL REPORT ON AK • It is not known if he had any convictions as a juvenile. He was cautioned by the Surrey Police for theft on 08/04/90 and 23/07/90 at the age of 17. On 24/09/91, at the age of 18, he was convicted of ABH, common assault, resisting a police constable, obtaining property by Little is known about each offence.d failing to surrender to custody and to bail at L Court. • On 28/07/98, he was convicted of wounding with intent to cause GBH and was sentenced to 5 which he was sentenced to a community service order for sixty hours. On 13/03/2014 he was fined £1500 and sentenced to 4 years in prison for severe animal cruelty, which involved dismembering and showcasing various stolen domesticate animals, to which he showed no remorse. On the 13/04/20, it was reported that he was walking down the street with his to his girlfriend and without warning, AK broke a bottle in the victim’s face, explaining that the victim had tried to kiss his girlfriend, so the assault was justified. Although he had consumed alcohol, he was coherent and rational when seen by a forensic medical examiner at the time. • During his prison sentence, he was initially categorised as a category C prisoner. It is reported that he harmed himself by cutting his leg with a razor blade and assaulted prison staff on two categorised as a category A prisoner where he assaulted prison officers causing one officer significant facial injuries. He wrote several complaints which are repetitive and at times show evidence of thought disorders, along with persecutory beliefs. He refused to engage with prison psychology service, or the mental health in-reach team. He was then transferred to X hospital under Sections 47/49 of the Mental Health Act.What are the differential diagnoses and what are the factors suggesting each MENT AL HEALTH TRIBUNAL REPORT ON AK • It is not known if he had any convictions as a juvenile. He was cautioned by the Surrey Police for theft on 08/04/90 and 23/07/90 at the age of 17. On 24/09/91, at the age of 18, he was convicted of ABH, common assault, resisting a police constable, obtaining property by Little is known about each offence.d failing to surrender to custody and to bail at L Court. • On 28/07/98, he was convicted of wounding with intent to cause GBH and was sentenced to 5 which he was sentenced to a community service order for sixty hours. On 13/03/2014 he was fined £1500 and sentenced to 4 years in prison for severe animal cruelty, which involved dismembering and showcasing various stolen domesticate animals, to which he showed no remorse. On the 13/04/20, it was reported that he was walking down the street with his to his girlfriend and without warning, AK broke a bottle in the victim’s face, explaining that the victim had tried to kiss his girlfriend, so the assault was justified. Although he had consumed alcohol, he was coherent and rational when seen by a forensic medical examiner at the time. • During his prison sentence, he was initially categorised as a category C prisoner. It is reported that he harmed himself by cutting his leg with a razor blade and assaulted prison staff on two categorised as a category A prisoner where he assaulted prison officers causing one officer significant facial injuries. He wrote several complaints which are repetitive and at times show evidence of thought disorders, along with persecutory beliefs. He refused to engage with prison psychology service, or the mental health in-reach team. He was then transferred to X hospital under Sections 47/49 of the Mental Health Act. MENT AL HEALTH TRIBUNAL REPORT ON AK • It is not known if he had any convictions as a juvenile. He was cautioned by the Surrey Police for theft on 08/04/90 and 23/07/90 at the age of 17. On 24/09/91, at the age of 18, he was convicted of ABH, common assault, resisting a police constable, obtaining property by Little is known about each offence.d failing to surrender to custody and to bail at L Court. • On 28/07/98, he was convicted of wounding with intent to cause GBH and was sentenced to 5 which he was sentenced to a community service order for sixty hours. On 13/03/2014 he was fined £1500 and sentenced to 4 years in prison for severe animal cruelty, which involved dismembering and showcasing various stolen domesticate animals, to which he showed no remorse. On the 13/04/20, it was reported that he was walking down the street with his to his girlfriend and without warning, AK broke a bottle in the victim’s face, explaining that the victim had tried to kiss his girlfriend, so the assault was justified. Although he had consumed alcohol, he was coherent and rational when seen by a forensic medical examiner at the time. • During his prison sentence, he was initially categorised as a category C prisoner. It is reported that he harmed himself by cutting his leg with a razor blade and assaulted prison staff on two categorised as a category A prisoner where he assaulted prison officers causing one officer significant facial injuries. He wrote several complaints which are repetitive and at times show evidence of thought disorders, along with persecutory beliefs. He refused to engage with prison psychology service, or the mental health in-reach team. He was then transferred to X hospital under Sections 47/49 of the Mental Health Act.Personality disorders • previous classifications exhibiting major limitationsto • underdiagnosismplexity and inconsistency led to • Minimal consideration of severity • Rigidity of diagnoses • Dissocial, borderline and mixed PD • No more categories of personality disorders • Internalising and externalising traits • Mild, moderate and severe due to distribution along a dimension • Assessment based on prominence of abnormal traits, impact and risk to themselves and to others • Personality difficulty – new conceptDissocial Personality Disorder • Failure for the patients to conform to societal normality regarding lawful behaviour and empathy • Often show lack of remorse • There is general disregard and violation of other people’s human and moral rights • Aggression and irritability is common, with a typical history assaults • More common in menDiagnostic Hierarchy MENTAL HEALTH TRIBUNAL REPORT ON AK • During hisadmission at X hospital, AK behaved with paranoid behaviours, such as no accepting food unless it was sealed, and being overly sensitive to others’ words and actions. On occasions when interacting with ward staff, he wouldintimidate the nursing staff and duty social workers and threaten to kill the doctors. He would also often be found locking himself in his room, spitting at other patients. He has had a history of multiple administration of oral antipsychotic medication.as a result, restrained for • On 25/05/21 he became hostile and refusedto answer questions when confronted with allegations about intimidationof other patients and refused to engage in psychology and at the anger management and study religion.However, he continued to behave aggressive and odd,n room to observed to be talking to milk cartons. When approached by staff, he wouldcontinue to be suspicious, insisting that specific members of the nursing team were planting thoughts and ideas into his mind, and removing all his thoughts of retaliation, making him vulnerable. MENTAL HEALTH TRIBUNAL REPORT ON AK • During hisadmission at X hospital, AK behaved with paranoid behaviours, such as not accepting food unless it was sealed, and being overly sensitive to others’ words and actions. On occasions when interacting with ward staff, he would intimidate the nursing staff and duty social workers and threaten to kill the doctors. He would also often be found locking himself in his room, spitting at other patients. He has had a history of multiple administration of oral antipsychotic medication.as a result, restrained for • On 25/05/21 he became hostile and refusedto answer questions when confronted with allegations about intimidationof other patients and refused to engage in psychology and at the anger management and study religion.However, he continued to behave aggressive and odd,n room to observed to be talking to milk cartons. When approached by staff, he wouldcontinue to be suspicious, insisting that specific members of the nursing team were planting thoughts and ideas into his mind, and removing all his thoughts of retaliation, making him vulnerable. MENT AL HEAL TH TRUBUNAL REPORT ON AK Mental State Examination • along with three members of the nursing staff. During this interview, he was dressed in a white vest andom baseball shorts, with socks and slippers, and a baseball cap appropriate for the weather. He was well kempt, with no piercings or obvious scars and unusual tattoos. No signs of neglect was noted. Throughout the interview, he was cooperative and there was good rapport and eye contact, although he was initially slightly polite and spontaneous, but showed signs of thought disorder such as “human beings are like gods, thepeech was environment is subjected to our whims in much the same way as when we talk about classical Greek Gods and how they controlled life on Earth in the same way as we would capitalise economies that embody the hallucinations of any modality was noted. His subjective mood was “bearable”, objectively described as euthymic and his affect was noted to be congruent with his mood, reactive with appropriate responses to emotional cues. He denied having any thoughts of self harm or suicide. AK was oriented to time, place and person, with good short term memory and concentration. He did not accept that he had a mental illness, or hypersalivation and paranoia, and could not see any benefit from being on his antipsychotic medication, instead insisting that they were the cause of his paranoid symptoms. He has stated that he hates being in a psychiatric hospital and is determined to fight the system. MENT AL HEAL TH TRUBUNAL REPORT ON AK Mental State Examination • along with three members of the nursing staff. During this interview, he was dressed in a white vest andom baseball shorts, with socks and slippers, and a baseball cap appropriate for the weather. He was well kempt, with no piercings or obvious scars and unusual tattoos. No signs of neglect was noted. Throughout the interview, he was cooperative and there was good rapport and eye contact, although he was initially slightly polite and spontaneous, but showed signs of thought disorder such as “human beings are like gods, thepeech was environment is subjected to our whims in much the same way as when we talk about classical Greek Gods and how they controlled life on Earth in the same way as we would capitalise economies that embody the hallucinations of any modality was noted. His subjective mood was “bearable”, objectively described as euthymic and his affect was noted to be congruent with his mood, reactive with appropriate responses to emotional cues. He denied having any thoughts of self harm or suicide. AK was oriented to time, place and person, with good short term memory and concentration. He did not accept that he had a mental illness, or hypersalivation and paranoia, and could not see any benefit from being on his antipsychotic medication, instead insisting that they were the cause of his paranoid symptoms. He has stated that he hates being in a psychiatric hospital and is determined to fight the system. Schizophrenia • Paranoid schizophrenia is most common • Symptoms • Schneider’s 1 rank symptoms • Auditory hallucinations • Thought disorder • Passivity phenomena • Delusional perceptions • Loosening of associations • Negative symptoms – affect avoliation, apathy, asocialtya, • (ICD10) or 6 months (DSM5)st 1 month Typical antipsychotic st medications – 1 generation • Dopamine D2 receptor antagonists – block dopaminergic transmission in the mesolimbic pathways • Chlorpromazine – used as anti-emetic in palliative care • Very sedating – good for violent patients • Flupentixol, haloperidol • Side effects • Extrapyramidal • Parkinsonism • Acute dystonia – procyclidine/benztropine • Akathisia • Tardive dyskinesia – tetrabenazine • Antimuscarinic • Sedation and weight gain • Hyperprolactinaemia • Metabolic syndrome • Neuroleptic malignant syndrome • Reduces seizure threshold • Increased QT • Increase stroke and VTEAtypical antipsychotic nd medications – 2 generation • Used 1 line in schizophrenia • Olanzapine, risperidone, quetiapine, paliperidone, aripiprazole, clozapine • Side effects • EPS • Significant reduction in extrapyramidal side effects, but they still exist • Agranulocytosis • Depression and anxiety • Antimuscarinic • HyperprolactinaemiaClozapine • Used for resistant schizophrenia • Requires prescription from a doctor who is registered with the CPMS • All patients to be prescribed clozapine must be registered with CPMS as well • Side effects • Agranulocytosis • Neutropaenia • Reduced seizure threshold • Constipation • Tachycardia • Myocarditis • Hypersalivation • Weight gain • Sedation • Upon initiation • FBC, fasting glucose, LFTs, U&Es, blood lipids, creatinine kinase, prolactin • BMI, blood pressure, pulse • Smoking cessation and consumingalcohol increases serum clozapine levels MENT AL HEAL TH TRIBUNAL REPORT ON AK Opinion • he has reported being involved in school fights, and first contacted the criminal justice system at the age of 17. Since, he has had a decline in his social functioning and as an adult, he has developed a psychotic illness characterised by bizarre behaviour with hostility and sudden anger, thought disorders and suspiciousness with persecutory ideation and religious beliefs. He appears guarded with his experiences and remain reluctant to provide information to mental health services. In from a paranoid schizophrenic illness (ICD10 F20.0).onse to antipsychotic medication, it is in my opinion that he is suffering • no ability to empathise. His personality disorder has features of dissocial traits. a callous lack of concern for others with • Mental Health Act 2007. His disorder has been associated with significant aggressive and disturbed behaviour, and is therefore currently of the nature and degree that would warrant his detention in hospital for medical treatment necessary for his own health, and for the protection of others. It is my opinion that the appropriate treatment is available within X hospital, initially anti-psychotic medication, but also psychological therapy to improve his understanding and insight into his condition. • He has responded to antipsychotic medication in the past, and there is some evidence that his mental state is beginning to improve. He can be pleasant and is clearly an intelligent man who is struggling to come to terms with his illness. If services. In these circumstances, it is highly likely that his mental health will deteriorate and he will present a high risk of further interpersonal violence. Finally, a Section 117 meeting will be convened prior to his tribunal.