Question 2

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She had become withdrawn and isolated.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.

Your tasks are to:

 Elicit further relevant information from the examiner regarding Tara’s presentation in order to
help you understand her current difficulties, including risks to herself and/or others
 Develop an appropriate management plan for her and describe that to the examiner, focusing
upon immediate and medium to longer-term issues that would require attention

Provisional Diagnosis
First Episode Psychosis in the context of cannabis use and family history of schizophrenia

*Diagnostic criteria for brief psychotic episode

 >1/4 POSITIVE symptoms of criterion A for at least >1 day but <1 month with
at least one of (1), (2) or (3)
 Hallucinations (1)
 Delusions (2)
 Formal Thought Disorder (3)
 Catatonic behaviour/grossly disorganise (4)
 Negative symptoms – affective flattening, alogia, anhedonia, avolition,
asociality

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

Assessment and management:

 History/collateral, risk assessment, examination (MSE)
 For the sake of being thorough it may be appropriate to repeat physical examination (in
the presence of parents/chaperone) and review investigations completed to exclude
organic cause
 Management should be done according to the biopsychosocial framework

Clinical History (from patient and collateral obtained from parents)

History of Presenting Complaint
 Initially attempt to take a history from Tara
 Symptoms of depression (M-SIGECAPS 5/9 for more than 2 weeks)
 Mood
 Sleep
 Interest
 Guilt
 Energy
 Concentration
 Appetite
 Psychomotor changes
  Suicidality
 Symptoms of mania (GST-PAID 3/7 for more than 1 week)
 Grandiosity
 Sleep – feeling rested after only 3 hours
 Talkative (pressured, hard to interrupt)
 Pleasurable activities, painful consequences – disinhibition
 Activity – social/sexual/psychomotor agitation
 Ideas (flight of) – lots of ideas, how many do you accomplish
 Distractible
 Note that hypomanic episodes are the same but last 2-4 days and do not
cause social/occupational dysfunction
 Symptoms of anxiety *waTCH-ERS (3/6 for 6 months)
 Worry
 Anxiety
 Tension in muscles
 Concentration difficulty
 Hyperarousal – irritability
 Energy decreased
 Restlessness
 Sleep disturbances
 Ask about psychotic symptoms (delusions, A/V hallucinations, thought
disorder)
 Screen for organic causes (illness, drug intoxication/withdrawal)
 Screen for impairment in social, occupation or other important areas of
functioning)

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)

Screen substance/drug-induced or organic causes

 Alcohol/drugs
 Pain medications

Past Psychiatric Hx
 Including medications (past or ongoing)
 Including previous inpatient/outpatient services

Medical History
 Medical conditions and medications
 Surgeries
 Allergies

Substance History (D&A)

 Important to ask about cigarettes and coffee
 CAGE – cutting down, annoyed about commends, guilty, eye-opener

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)

Forensic Hx (arrests, convictions, sentences)

Family Hx (especially of psychiatric illness)

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.

Short-Term – relieve current symptoms

 Biological
 2nd generation atypical antipsychotics (aripiprazole, quetiapine, olanzapine,
amisulpride, risperidone)
 Aripiprazole 2.5mg PO OD
 Up-titrate after 2 weeks to 10-15mg  maximum of 30mg
 Quetiapine – 25mg PO BD
 Up-titrate after 3+ days to 150mg BD
 Continue to up-titrate as tolerated  400-800mg daily
 Ensure vitals, metabolic screen, ECG taken prior to commencement of anti-
psychotics
 +/- anxiolytics for agitation/anxiety/insomnia (SSRI) for 2-6 weeks
 Withdrawal
 Cannabis – supportive treatment
 Alcohol – thiamine, benzos
 Psychological
 Counselling
 Social – early psychosis intervention program

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