Professional Documents
Culture Documents
You are working in the adolescent mental health inpatient ward. Tara is a 17-year-old girl, who
was admitted to the ward last night from the emergency department (ED). In the ED she was
described as being agitated, angry and threatening. Her parents brought her in and are very
concerned about her. No significant medical issues were identified during assessment in the ED
and she was admitted to the adolescent ward for assessment and management.
Her parents said that her behaviour had changed about 3 months ago. She was a good natured
and sociable person up until then; she had been good in her studies and was also good in sports.
However, in the last few months she had not being doing well school and had in fact stopped
attending for the last few weeks. She performed poorly in her last school test about 2 months ago.
She had become withdrawn and isolated. Her parents suspected she had been going out with a
group of friends who were using alcohol and cannabis, but had stopped this social contact, often
now using cannabis by herself. They reported that she has been behaving oddly also, more
recently.
Her paternal uncle is reported to have had schizophrenia and needed to be hospitalised on
several occasions. Tara is the second of three children to her parents and lives in an intact family.
There is no history of any significant medical issues in the past and Tara has not had any contact
with mental health services before.
Your registrar is away on training today and your consultant has requested that you review this
patient urgently and then discuss with him. The patient has been insisting on going home and
ward staff are concerned.
Provisional Diagnosis
First Episode Psychosis in the context of cannabis use and family history of schizophrenia
Differential Diagnoses:
Psychotic Disorders
Drug-induced psychosis
Schizophreniform disorder
Schizoaffective disorder
Schizophrenia
Mood disorders
Bipolar Affective Disorder
Major Depressive Episode
Personality Disorders
Cluster A: paranoid, schizotypal, schizoid
Organic causes
Space occupying lesion
Head trauma
Electrolyte abnormalities
Hypothyroidism
Cancer/Infection
Approach:
When talking to Tara and her family I would use a non-judgmental, open-minded and
collaborative approach.
It is important to consider the safety of all parties involves in the assessment:
Sit close to the exit - >2m away from the patient
Have appropriate security/duress alarm
Be prepared to de-escalate the situation if need be (verbal and security
Risk assessment
Offer to do a HCR-20 for assessing risk of violence
Screen for deliberate self-harm, suicidal and homicidal ideation/activity
Risk to self (suicide, impulsive, auditory hallucinations, isolation, reputation,
financial harm)
Females attempt suicide 4x more often than men
Assess suicidal: ideation/plan/intent/access/prior action/protective factors
Risk to others (homicidal ideation/activity)
Vulnerability (lack of insight, any dependents)
Risk of absconding/non-compliance (any hx of non-compliance, poor insight/judgement)
Past Psychiatric Hx
Including medications (past or ongoing)
Including previous inpatient/outpatient services
Medical History
Medical conditions and medications
Surgeries
Allergies
Developmental Hx
Anxiety/temperament
Abuse/domestic violence or any other trauma
Prenatal and perinatal
Early childhood (to age 3)
Middle childhood (to age 11)
Late childhood (to age 18)
Psychosocial Hx (HEADSS)
Home
Family structure
Any abuse/trauma
Religious beliefs
Education/Employment
Performance in school
Activity
Exercise and Eating
Extracurriculars
Friend groups
Drugs
Illicit drugs
Alcohol
Cigarettes/Vaping
Sexuality
Relationships
Sexual activity/orientation
Gender
Suicidality
Discussed previously
Collaborative Hx
Parents
GP
Examination
Mental State Examination
ABSEPTICJ
Appearance
Age/Sex
BMI
Ethnicity
Self-neglect, evidence of self-harm
Behaviour
Eye contact
Facial expressions
Mannerisms
Level of arousal
Engagement
Cooperation/attitude to examiner
Psychomotor activity – akathisia, catatonia
Speech – rate, tone, volume, fluency, slurring/stuttering/accents
Emotions
Mood
Affect – type, range, appropriateness, congruence with mood
Perceptual state
Hallucinations – auditory, visual, olfactory, tactile, gustatory
Derealisation
Depersonalisation
Thought Form – derailment, tangentiality, flight of ideas, incoherence, neologisms,
thought-blocking, perseveration, echolalia, poverty of thought, poverty of content
Thought Content
Delusions
Obsessions/Compulsions
Insight
Do you think there’s anything wrong with you at the moment?
Do you think your parents/friends would say that there’s something different
about you?
Cognition
Consciousness – alert/intoxicated
Orientation – time, place, person
Attention and concentration – serial 7s
Short-term memory
Formal MMSE
Judgement
Physical Examination
Constitutional symptoms or infection or malignancy
Signs of hypothyroidism
Signs of O/D and Intoxication
Investigations
Screen
Bedside – urinalysis, drug screen +/- ECG (baseline QT before starting
antipsychotic + assess metabolic syndrome)
Laboratory – FBC, EUC/CMP, LFT, TFTs, BSL, blood alcohol levels
Imaging – CT head or MRI
Consider LP if considering CNS infection or EEG if seizure history
Management
Given that schizophrenia is a neurodegenerative disorder, it is paramount that individuals
with first episode psychosis receive early intervention.
Medium Term
Biological
Anti-psychotic treatment
Follow-up and monitoring for efficacy and side-effects
If not working 6 weeks after up-titrating to therapeutic dose – taper + add
new medication
Consider Clozapine/ECT in treatment-resistant psychosis
Monitoring and Optimising smoking, nutrition, alcohol, physical activity risk
factors and metabolic status
Psychological
Psychoeducation
Family intervention
CBT
Management of substance use
CBT, group therapy, support groups, motivational interviewing
Social
Case management and linked with early psychosis intervention program
Monitor performance at school and functioning
Involvement of GP – mental health plan and management plan
Long-Term
Biological
Optimise co-morbidities
Maintaining lifestyle modifications (nil drug-use, improved sleep, diet and
exercise)
Follow-up
Monitoring for worsening behaviour/aggression, suicidal ideation and
substance use
Psychologist referral