mental health history and examination

Introduction

an ability to rapidly assess a patient from a mental health perspective is important
this includes monitoring for change over time and this further supports the importance of continual documentation of their mental state to allow comparisons
is there a behavioural management plan in place for this patient?
- check before you see the patient for your own safety but also to ensure a consistent approach and management in often difficult and complex patients.
ensure your interactions do not escalate frustrations or anger
- lack of communication is a common cause - ensure there are regular check-ins with the patient
- do not make promises that can't be kept - this will undo any rapport or trust you have built
- ensure physical needs such as hunger, thirst, need for toileting, etc are met
- be mindful of YOUR OWN body language, tone of voice and how you communicate:
  - checking the time sends message that you are time poor and they are not a priority
  - crossed arms is generally not conducive to developing rapport or caring perceptions
  - ensure it matches what you say
consider communicating with patients using the heart-head-heart communication model
- an empathetic and mindful model for communication in healthcare settings
- a three-stage positive interaction:
  - First, a compassionate approach (heart)
    - eg. “I am sorry about how long it is taking, you must feel very frustrated right now”
    - eg. “I can see how upset this has made you. I'm sorry that… ”
  - Secondly, a pragmatic and outcome-focused approach (head)
    - eg. “how about I keep you up-to date-with the waiting time, I’ll check and come back”
    - eg. “it is important you speak respectfully to staff. raising your voice can appear intimidating and make staff feel uneasy”
  - Lastly, another compassionate, empathetic approach (heart)
    - eg. “please feel free to come and talk to me if you have any more questions, I am here to help”
- use encouragers (brief phrases or non-verbal communications) to encourage them to engage and express
- use paraphrasing to reflect back what they have said so they perceive that you have listened
- use summarising to ensure communication is perceived correctly:
  - eg. “let me see if I have got this right ….”
- see also http://www.aipc.net.au/student_bonuses/Counselling%20Micro%20Skills.pdf

the irritable patient
- ensure personal safety
  - ensure you have your phone or personal duress alarm and know where the permanent duress alarms are sited
  - don't place yourself in a space where you could be trapped
  - ensure you are aware of your entry/exit and that there is no clutter to block your exit
  - ensure high risk patients have been searched according to hospital procedures prior to approaching
  - stay at a safe distance wherever possible
  - enter a space only when safe to do so
  - maintain a height power position - do not remain seated if a patient stands up
  - ensure patient does not feel trapped as they may feel their only way out is with violence
  - check patient notes to ascertain likely triggers to violence such as past traumas (trauma-informed care¹⁾ - assumes ALL patients have a history of traumatic stress)
    - disasters / war
    - child abuse / sexual abuse / family violence
    - relationship conflict
    - anniversaries of trauma
    - past interactions with police/ambulance/MH/Drs
    - intellectual disabilities
    - psychiatric or organic issues causing delirium, aggression (especially recent use of metamphetamine or drunkenness)
    - survivors of past trauma:
      - may engage in behaviours of avoidance, social withdrawal, substance use, and self harm
      - may experience disassociation, feelings of powerlessness, defensiveness, anger or distrust
      - are likely to be on high alert and be more reactive to stimuli and triggers resulting in fight, flight or freeze reactions
  - be self-aware - pay attention to your emotions, attitudes and behaviours in response to specific situations
    - know your own triggers (eg. personal remarks)
    - use self-talk to keep calm
    - ignore personal insults
    - avoid placing blame on others or being defensive
    - actively listen and wait rather than interrupting and use empathetic communication such as heart-head-heart model
- call for help EARLY
  - notify those in charge and security
  - postpone any care provision or interventions such as blood tests or IV cannula until a safety plan is in place, this may require a the presence of an additional staff member or security, or calling a hospital security code to ensure the security team are present to allow safe intervention or care provision task
- de-escalate
  - if possible, increase visibility to the patient
  - if possible, reduce environmental stimuli
  - address any basic comfort and physical needs such as need to go to toilet
  - engage with transparency, honesty and clarity and don't make promises you can't keep
  - acknowledge the situation, where possible, provide a safe and transparent environment
  - clarify your role and be clear what you can and can't do
  - include patient in decisions made about them, be respectful of their choices
  - consider use of prn medication
  - consider use of calming measures such as stress balls, past time packs and other distraction options
- document
  - ensure this event information and the safety risk is handed over to subsequent care teams

Features to look for

level of alertness
level of agitation
- relaxed
- body language - open or withdrawn
- fidgety
- raised tone of voice
- threatening
- verbally abusive
- physically abusive
level of self-care or presence of injuries or drug use
how engaged they are in conversation
- eye contact
- spontaneity of answers
are there features suggestive of psychosis?
- hallucinations, delusions, paranoia, and/or thought disorder
- this may be psychiatric or organic (eg. drug-induced, drug withdrawal or a delirium)
  - visual hallucinations tend to be organic rather than psychiatric
- Schizophrenia
  - Characterized by distortions in thinking, perception, emotions, language, sense of self, and behaviour. Common experiences include hallucinations – hearing voices or seeing things that are not there – and delusions – which can be fixed, false beliefs.
are there features of mania?
- Bipolar (formerly “manic depression”)
  - a period of mania is a sustained period of abnormally elevated or irritable mood and is evidenced by rapid speech, flight of ideas, feelings of super powers, irrational spending or charity
are there features of depression or suicidality?
- loss of interest / anhedonia
- persistent low mood
- poor sleep
- do they have suicidal ideation, if so, do they have a plan and what are their risk/protective factors?
are there features of personality disorder?
- may have trouble perceiving and relating to situations and people. This can cause significant problems and limitations in relationships, social activities, work and school.
- in some cases, the person may not realise that they have a personality disorder because the way they think and behave seems normal to them.

¹⁾

https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national-consensus-statement-essential-elements-recognising-and-responding-deterioration-persons-mental-state