Showing posts with label Assessment. Show all posts
Showing posts with label Assessment. Show all posts

Wednesday, 17 March 2021

Assessment and Management of The Risk of Violence in Schizophrenia

Assessment and Management of The Risk of Violence in Schizophrenia

Scenario

A 21-year-old lady with the diagnosis of schizophrenia informs you she will kill her neighbour tomorrow as she has ruined her life. She tells not to disclose this to anyone.
  1. How will you assess the homicidal risk in this patient?
  2. What treatment and follow up recommendations will you make in this case?

Clinical Assessment 

Listen to the patient and develop a therapeutic relationship. 

begin the assessment and enquire about her demographics. 

Enquire about the issue that she brought up—she will kill her neighbour. 

Elaborate on how she thinks her neighbour has ruined her life. 

Explore her thoughts and whether the patient may have persecutory delusions

Assess how much resentment she feels?

Follow up with inquiry about her mood, esp. about irritability and depression

How she plans to commit the act

Has she threatened the person?

Whether she has done so in the past

If so, what provoked such an incident

Whether the provoking factor is still present

Whether she possesses a weapon.

How easily she can access her

Whether she uses alcohol or substance

Psychiatric history and mental state

Whether she has other psychotic symptoms, e.g., commanding hallucinations

Negative symptoms (reduced likelihood)

Elicit relevant personal history

Especially whether she is single, divorced or separated

Who she lives with?

Her socioeconomic circumstances

Any stressful circumstances she might be passing through

 

Tools to Assess the Risk of Violence

Buss-Durkee Hostility Inventory

       75 (true/false)-item questionnaire

       Used to assess cynicism and distrust

Hostility and Direction of Hostility Questionnaire

The 51-item self-report questionnaire with 5 subscales. 

Used to assess the range of manifestations of aggression, hostility, and punitiveness; distinguishes hostility as they direct it either externally (extra-punitive: psychopathic, paranoid, hysterical) or internally (internal-punitive: guilt, self-criticism)

Aggression Risk Profile

       39-item rating scale

Identifies the characteristics of chronically aggressive patients, to foresee future manifestations of violent behaviour

Suicide and Aggression Survey

Semi-structured clinician-administered interview and research tool; divided into 5 parts

Elicits a brief medical history, recent and lifetime suicidality, and tendency to social violence; measures recent and past aggressiveness expressed by suicidal acts and thoughts

Management

  1. Clozapine for schizophrenia, which also reduces the risk of violence (Farooq and Taylor 2011)
  2. Address the modifiable risk factors identified
  3. Inform the potential victim as a precautionary measure (which is also a legal/ethical responsibility)
  4. If community services are available, we should consider assertive outreach.
  5. If the patient is violent, we can also consider ECT.
  6. Family therapy, CBT and other psychosocial interventions for schizophrenia.

Friday, 8 January 2021

Important Questions About History of Drug Use

Important Points about the History of Drug Use

  1. Regular or intermittent
  2. Amount (know the units)
  3. Pattern dependence/withdrawal 
  4. Impact on work, relationships, money, police 
  5. Screening questionnaires e.g. CAGE

Behavior and Body Language During History Taking

Behavior and Body Language During History Taking

  1. Establish and maintain eye-contact and rapport. 
  2. Relaxed non-threatening posture and appear unhurried. 
  3. Use facilitated noises (I see, okay, etc.)
  4. Pick up on nonverbal cues 
  5. Acknowledge what they are saying 
  6. Show a willingness to understand 
  7. Do not offer opinion/advice to early 
  8. Control over-talkativeness with polite authority at the right time

Thursday, 7 January 2021

Differentiating Factors of Epileptic and Non-epileptic Fits

Differentiating Factors of Epileptic and Non-epileptic Fits

Factors That Favor Epileptic Fits


The following Favor epileptic fits. 
An abrupt onset
A stereotyped course lasting seconds to a few minutes.
Tongue biting, especially on the sides
Urinary incontinence during the fit
Evidence of cyanosis, for example, face turning blue.
Injury during the episode
Prolonged postictal confusion

Favour Non-Epileptic Fits


Treatment resistance to over two antiepileptic drugs.
Antiepileptics do not affect seizures.
Fits occur with specific environmental or emotional triggers.
Presence of witnesses, for example, family members at the time of an event.
History of chronic pain, fibromyalgia, chronic fatigue, syndromes.
History of comorbid psychiatric illness, personality disorder or substance abuse.
History of remote or current abuse or trauma.
Presence of repeatedly normal EEGs in the presence of recurrent seizures.
Drawn from Benbadis and LaFrance (2010).

Sociological features of Psychogenic Non-Epileptic fits

Gradual onset.
Rapid postictal re-orientation.
Undulating motor activity.
Side-to-side, head shaking.
Closed eyelids during the event.
An event lasting over two minutes.
Resisted eyelid opening.
Lack of cyanosis.
Partial responsiveness during a fit.
Drawn from Benbadis and LaFrance (2010) and Syed et al. (2011).





What are the points you would elicit to differentiate between epileptic and non-epileptic fits?
Does the fit present in diverse ways, or does it always present the same way?
What is the duration of the fits? Does that vary? 
Do you experience any post-ictal headache?
How do you feel after the fit? 
Do you think clearly or do you feel confused?
How soon do you recover after the fit?
Have you noticed any factors that trigger the fits? 
How frequently does the fit occur?
Has it ever occurred while you were sleeping, and someone noticed you having a fit?
Have you injured your tongue ever? Can you show me if the injury is to the side of your tongue?
Sometimes people may void urine because of the fits. Has that ever happened while you had a fit?
Has anyone noticed and told you that your face turned blue? 
Does it occur all sudden or do you feel like it will happen and then the fits happen?
Do you take any treatment for a psychiatric disorder?
Have you ever experienced an injury during the Episode?
Does the fit occur in a specific situation or place?
Is there any pattern to the episodes that you may have noticed?
Okay, this last question is slightly sensitive, but this is relevant so I must ask you: Do you have any childhood history of adverse experiences like punishment, abuse? The information you provide we always treat that confidential. Is there any history of sexual abuse? 

  1. Anwar H, Khan QU, Nadeem N, Pervaiz I, Ali M, Cheema FF. Epileptic seizures. Discoveries (Craiova). 2020;8(2):e110-e110. doi:10.15190/d.2020.7
  2. Benbadis SR, LaFrance Jr. WC. Clinical features and the role of video-EEG monitoring. In: Schachter SC, LaFrance Jr WC, eds. Gates and Rowan’s Nonepileptic Seizures, 3rd ed. New York: Cambridge University Press, 2010.
  3. Syed TU, LaFrance Jr. WC, Kahriman ES, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011; 69(6): 997-1004.

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