Learning outcomes theme 4
Week 13
• know the differential diagnosis of this week’s main health issue and are able to distinguish between these
disorders on the basis of the patient interview, the psychiatric examination and additional screening
Emergency psychiatry occurs when there is a disruption of cognitive, affective and conative functions, which requires
immediate treatment. The goal of the psychiatric interventions is to restructure an emergency situation so that the
start or continuation of (psychiatric) care is possible in a regular manner
- If the patient adequately answers the question about their personal data, they are probably clear-headed enough.
- Decreased consciousness with hallucinations may indicate a delirium.
- Disorientation and memory loss could indicate dementia.
- Depersonalization and derealization can occur in extreme fatigue, psychosis spectrum and depressive disorders.
- Auditory hallucinations can occur in psychosis spectrum disorders.
- Accelerated thinking with overconfidence occurs in manic inhibition and drug abuse.
- Confusion occurs, among other situations, in psychosis spectrum disorders and dementia.
- Incomprehension and simple language are common in people with intellectual disabilities, but also in those who
are not native speakers.
- A sad mood can, of course, indicate a depressive disorder and is often accompanied by suicidal ideation.
- Anxiety occurs in many disorders, but may also indicate a panic disorder.
- Excessive anxious and dependent behaviour may indicate a cluster C personality disorder.
- Behavioural disorders and severe arousal can indicate inhibition, for example in a mania or in case of drug use, or a
low frustration tolerance and impulse control in a personality disorder.
• know other causes of ‘confused behaviour’ than psychiatric disorders
- Drug/medication induced: alcohol, amphetamines, cocaine, cannabis, LSD, analgesics, anticholinergics,
antidepressants, antipsychotics, CO, benzodiazepines.
- physical disorders: epilepsy, head injury, infection, dementia, deafness, migraine, hormonal disorders, metabolic
diseases
• can list the risk factors for psychosocial problems and their escalation
• know how the mental health crisis team assesses patients (confused or otherwise) with an acute care request
Emergency? → thorough history often not possible, but try to get necessary info: history and general systemic info
- appearance: cognitive, affective and conative functions
- limited somatic review of systems: ROS
- ask med/drug use
- simple neurological tests: i.e. hopping on 1 leg
----> after this: preliminary diagnosis
→ cause? Mainly psychiatric? Medical? Social? Serious or not? Acute/chronic? Is patient responsible?
I Main Category Area Core symptoms
First impressions — -Ill?
Unkempt, neglected?
Disturbed contact?
-Hostile, suspicious, anxious attitude?
Cognitive functions Consciousness, attention -Impaired or narrowed consciousness
& orientation -Intoxicated?
-Hypovigilance/hypervigilance of attention?
-Disorientation in time or place?
Memory -Anterograde or retrograde amnesia?
-Dissociative amnesia?
Intellectual functions -Judgement?
, -Illness awareness and insight?
-Intelligence
-Language
Imagination, perception -Visual or auditory hallucinations?
& self-perception -Derealization, depersonalization?
-Compulsive images?
Thinking: form -Tachyphrenia or bradyphrenia?
-Alogia, incoherence?
-Increased associative thought?
Thinking: content -Delusions?
-Obsessions?
-Preoccupations?
-Compulsive thoughts?
-Homicidal, suicidal thoughts?
Affective functions Mood & affect
Euphoric? Dysphoric? Depressed, anhedonic, desperate, suicidal, anxious, panic attacks?
Somatic symptoms Unstablesymptoms
-Somatic affect Shallow affect?disorder?
of a mood
& signs Anxiety equivalents? Pseudoneurological phenomena?
Conative functions Psychomotor function -Catalepsy, echopraxia, verbal perseveration?
& speech -Delay, retardation, stupor, mutism?
I -Hyperactivity, agitation? ,
-Speaking loudly?
Behaviour -Expansive, intrusive, aggressive?
-Apathetic, lethargic?
-Substance abuse?
-Compulsive behaviour?
-Suicidal or impulsive behaviour?
Personality — -Gifted, intellectual disorder?
traits -Mistrusting?
Lying, impulsive, aggressive, unstable affect, uncontrolled, challenging, dramatizing,
arrogant?
• can write a rational treatment plan for a patient with an acute confused mental state
To determine the intervention:
- can the patient stay at home with support and/or should the patient be admitted and if so, should they be
admitted to a secure unit with seclusion capability, or can the patient also be admitted to an open unit?
- Does the patient have to detoxicate in a detoxification department of an addiction clinic? Should the patient be
involuntarily be admitted?
• can describe psychiatric crisis interventions and their indications
Emergency:
Sedation? → quick results desired →benzodiazepine (…pam) (often + antipsychotic)
Antipsychotics → haloperidol and zuclopenthixol (if also anxiety and agitation occur, add benzodiazepine)
Anticholinergic anti-Parkinson medication → i.c.o. extrapyramidal symptoms caused by antipsychotics
* antidepressants and mood stabilizers rarely used → takes longer time before they have an effect.
• know the risk factors for aggressive behaviour and the first signs of imminent aggression during a psychiatric
consultation
The risk of violence appears to be linked to the existence of a psychiatric condition caused by substances or
medication or by a somatic disorder and also to be linked to mania. The risk of aggression is also greater in
unemployed young men without an education and social networks, and in people who have recently been victims of
violence or have been victims of violence and abuse in the past. The best overall indicator is whether a patient has
been aggressive in the past. The psychiatrist will look for changes in body language that can give an indication of
impending aggression, such as posture (sitting on the edge of a chair, squeezing armrests, standing), speech (louder,
shrill or rude), motor behaviour (increasing agitation, tension and/or a balled up fist) and the mood (angry, irritated).
, Box 25.1 Screening for the likelihood of violent behaviour
- Have you been very angry lately?
- Have you ever had the urge to harm someone?
- Have you ever been afraid that you would lose control of yourself?
- Have you ever lost control and abused someone?
- Do you think that something like that could happen again soon?
• can apply the psychiatric examination in the assessment of a ‘confused person’
• can describe and apply the Risk-Need-Responsivity model used in forensic psychiatry
RNR – model: assesses and rehabilitates criminals in Canada
→The RNR model has not only contributed to the development
of offender risk instruments that predict as well as the
atheoretical, actuarial instruments but also provides information
useful for offender treatment.
→ the RNR model does not exclude attention to personal levels
of distress
based on three principles:
1) the risk principle asserts that criminal behaviour can be
reliably predicted and that treatment should focus on the higher risk offenders;
2) the need principle highlights the importance of criminogenic needs in the design and delivery of treatment;
3) the responsivity principle describes how the treatment should be provided.
→ two parts: general (cognitive social learning methods) and specific (fine tuning)
Given the research to date, to provide the best assessments and interventions correctional agencies need to:
a) embrace a general vision that it is in the best interest for all to provide cognitive behavioural services to offenders
b) select, properly train, and supervise staff in use of RNR assessments and delivery of services that adhere to RNR
c) provide policies and organizational supports for the RNR model
→ Agencies that that are able to achieve this level of commitment show significant reductions in recidivism
compared to agencies that fail to adhere to the risk-need-responsivity principles
TBS: the period per crime has to be at least 4 years in order to get tbs
• can name risk factors for (recurrent) criminal behaviour
Week 13
• know the differential diagnosis of this week’s main health issue and are able to distinguish between these
disorders on the basis of the patient interview, the psychiatric examination and additional screening
Emergency psychiatry occurs when there is a disruption of cognitive, affective and conative functions, which requires
immediate treatment. The goal of the psychiatric interventions is to restructure an emergency situation so that the
start or continuation of (psychiatric) care is possible in a regular manner
- If the patient adequately answers the question about their personal data, they are probably clear-headed enough.
- Decreased consciousness with hallucinations may indicate a delirium.
- Disorientation and memory loss could indicate dementia.
- Depersonalization and derealization can occur in extreme fatigue, psychosis spectrum and depressive disorders.
- Auditory hallucinations can occur in psychosis spectrum disorders.
- Accelerated thinking with overconfidence occurs in manic inhibition and drug abuse.
- Confusion occurs, among other situations, in psychosis spectrum disorders and dementia.
- Incomprehension and simple language are common in people with intellectual disabilities, but also in those who
are not native speakers.
- A sad mood can, of course, indicate a depressive disorder and is often accompanied by suicidal ideation.
- Anxiety occurs in many disorders, but may also indicate a panic disorder.
- Excessive anxious and dependent behaviour may indicate a cluster C personality disorder.
- Behavioural disorders and severe arousal can indicate inhibition, for example in a mania or in case of drug use, or a
low frustration tolerance and impulse control in a personality disorder.
• know other causes of ‘confused behaviour’ than psychiatric disorders
- Drug/medication induced: alcohol, amphetamines, cocaine, cannabis, LSD, analgesics, anticholinergics,
antidepressants, antipsychotics, CO, benzodiazepines.
- physical disorders: epilepsy, head injury, infection, dementia, deafness, migraine, hormonal disorders, metabolic
diseases
• can list the risk factors for psychosocial problems and their escalation
• know how the mental health crisis team assesses patients (confused or otherwise) with an acute care request
Emergency? → thorough history often not possible, but try to get necessary info: history and general systemic info
- appearance: cognitive, affective and conative functions
- limited somatic review of systems: ROS
- ask med/drug use
- simple neurological tests: i.e. hopping on 1 leg
----> after this: preliminary diagnosis
→ cause? Mainly psychiatric? Medical? Social? Serious or not? Acute/chronic? Is patient responsible?
I Main Category Area Core symptoms
First impressions — -Ill?
Unkempt, neglected?
Disturbed contact?
-Hostile, suspicious, anxious attitude?
Cognitive functions Consciousness, attention -Impaired or narrowed consciousness
& orientation -Intoxicated?
-Hypovigilance/hypervigilance of attention?
-Disorientation in time or place?
Memory -Anterograde or retrograde amnesia?
-Dissociative amnesia?
Intellectual functions -Judgement?
, -Illness awareness and insight?
-Intelligence
-Language
Imagination, perception -Visual or auditory hallucinations?
& self-perception -Derealization, depersonalization?
-Compulsive images?
Thinking: form -Tachyphrenia or bradyphrenia?
-Alogia, incoherence?
-Increased associative thought?
Thinking: content -Delusions?
-Obsessions?
-Preoccupations?
-Compulsive thoughts?
-Homicidal, suicidal thoughts?
Affective functions Mood & affect
Euphoric? Dysphoric? Depressed, anhedonic, desperate, suicidal, anxious, panic attacks?
Somatic symptoms Unstablesymptoms
-Somatic affect Shallow affect?disorder?
of a mood
& signs Anxiety equivalents? Pseudoneurological phenomena?
Conative functions Psychomotor function -Catalepsy, echopraxia, verbal perseveration?
& speech -Delay, retardation, stupor, mutism?
I -Hyperactivity, agitation? ,
-Speaking loudly?
Behaviour -Expansive, intrusive, aggressive?
-Apathetic, lethargic?
-Substance abuse?
-Compulsive behaviour?
-Suicidal or impulsive behaviour?
Personality — -Gifted, intellectual disorder?
traits -Mistrusting?
Lying, impulsive, aggressive, unstable affect, uncontrolled, challenging, dramatizing,
arrogant?
• can write a rational treatment plan for a patient with an acute confused mental state
To determine the intervention:
- can the patient stay at home with support and/or should the patient be admitted and if so, should they be
admitted to a secure unit with seclusion capability, or can the patient also be admitted to an open unit?
- Does the patient have to detoxicate in a detoxification department of an addiction clinic? Should the patient be
involuntarily be admitted?
• can describe psychiatric crisis interventions and their indications
Emergency:
Sedation? → quick results desired →benzodiazepine (…pam) (often + antipsychotic)
Antipsychotics → haloperidol and zuclopenthixol (if also anxiety and agitation occur, add benzodiazepine)
Anticholinergic anti-Parkinson medication → i.c.o. extrapyramidal symptoms caused by antipsychotics
* antidepressants and mood stabilizers rarely used → takes longer time before they have an effect.
• know the risk factors for aggressive behaviour and the first signs of imminent aggression during a psychiatric
consultation
The risk of violence appears to be linked to the existence of a psychiatric condition caused by substances or
medication or by a somatic disorder and also to be linked to mania. The risk of aggression is also greater in
unemployed young men without an education and social networks, and in people who have recently been victims of
violence or have been victims of violence and abuse in the past. The best overall indicator is whether a patient has
been aggressive in the past. The psychiatrist will look for changes in body language that can give an indication of
impending aggression, such as posture (sitting on the edge of a chair, squeezing armrests, standing), speech (louder,
shrill or rude), motor behaviour (increasing agitation, tension and/or a balled up fist) and the mood (angry, irritated).
, Box 25.1 Screening for the likelihood of violent behaviour
- Have you been very angry lately?
- Have you ever had the urge to harm someone?
- Have you ever been afraid that you would lose control of yourself?
- Have you ever lost control and abused someone?
- Do you think that something like that could happen again soon?
• can apply the psychiatric examination in the assessment of a ‘confused person’
• can describe and apply the Risk-Need-Responsivity model used in forensic psychiatry
RNR – model: assesses and rehabilitates criminals in Canada
→The RNR model has not only contributed to the development
of offender risk instruments that predict as well as the
atheoretical, actuarial instruments but also provides information
useful for offender treatment.
→ the RNR model does not exclude attention to personal levels
of distress
based on three principles:
1) the risk principle asserts that criminal behaviour can be
reliably predicted and that treatment should focus on the higher risk offenders;
2) the need principle highlights the importance of criminogenic needs in the design and delivery of treatment;
3) the responsivity principle describes how the treatment should be provided.
→ two parts: general (cognitive social learning methods) and specific (fine tuning)
Given the research to date, to provide the best assessments and interventions correctional agencies need to:
a) embrace a general vision that it is in the best interest for all to provide cognitive behavioural services to offenders
b) select, properly train, and supervise staff in use of RNR assessments and delivery of services that adhere to RNR
c) provide policies and organizational supports for the RNR model
→ Agencies that that are able to achieve this level of commitment show significant reductions in recidivism
compared to agencies that fail to adhere to the risk-need-responsivity principles
TBS: the period per crime has to be at least 4 years in order to get tbs
• can name risk factors for (recurrent) criminal behaviour
