Emergency Mental Health: Mental illnesses in the current society - Essay Example

?Assessment item 2 Mental illnesses have now become common health issues in the current society. These mental illnesses have also become common sources of emergency and paramedic calls and as such paramedics have become highly involved in the transport of these mentally ill patients. This assignment will consider the evaluation of issues and skills needed in the appropriate management of these situations. This case study will discuss a general case which may be attended by paramedics; it more or less seeks to allow the use of knowledge in the resolution of these issues, as well as the treatment and the transport of these patients. Section 20 of the Mental Health Act, as well as the legal, clinical and ethical skills provides the necessary tools in order to properly address the issues in this case study. In effect, the purpose of this study is for me to explore the knowledge and skills needed in the application of mental health practice in the pre-hospital care arena. It shall challenge me to explore the issues which are seen in the acute pre-hospital setting and to provide assistance in the developing of informed understanding of factors impacting on the pre-hospital care worker when providing for someone experiencing a mental illness in the emergency situation. Question 1 Identify three (3) risk factors for aggression escalation which are evident in the case study and with supporting rationale describe appropriate strategies which soon after your arrival you could make to help minimise these three (3) risk factors. 1. Internal factors (Duxbury and Whittington, 2004). This may be due to the patient’s mental illness itself which manifests with symptoms which include: deep feelings of insecurity; persistent impulsiveness; confused contradictory feelings; and self harm (Sane Australia, 2010). His deep feelings of insecurity are seen in his inability to cope with his failure and his expression of inappropriate anger towards other individuals he thinks is responsible for his failures, including his teachers (Sane Australia, 2010). He also has a very tenuous sense of self as manifested by his pitiful thoughts about his worth following failure in his academic activities. His persistent impulsiveness can be seen in his actions of locking himself in the science laboratories. This is a spur of the moment action which he thinks can aptly deal with his emotions at that particular point in time. His confused and contradictory feelings are also apparent with his eventual calming down and expressing that he was already okay and it was all a misunderstanding, and that he did not need any medical attention. However, it was still apparent in his demeanour that he was still very tense and his aggressive behaviour could be triggered again. Finally, his self-harming behaviour is very much apparent with his history of self-harming behaviour, and his current warnings of self-harming behaviour. Based on these internal factors, as a paramedic, my immediate actions would be to talk patiently and calmly to the patient to get rid of the tension and defensiveness. 2. Environmental Factors (Duxbury and Whittington, 2004). This may be due to the response of the school authorities to the patient’s actions which express strong feelings and lack of appropriate responses in to the patient. The treatment of the principal and the teachers are factors which prompt the escalation of aggression. The principal yelling for the patient to ‘get his butt out here’ are not very encouraging words and may in fact trigger aggression on a patient who already feels misunderstood and who feels like “no one understands him.” Although the case does not indicate it, aggressive behaviour among mental health patients may also be triggered by chaotic or unstable homes which often “encourage maladaptive aggressive behaviours” (Citrome, 2011). These individuals may sometimes become aggressive for various reasons at varying times. In this case, Jim became aggressive because he failed his trial exams, and his aggression manifested while he was at school. As a paramedic, another remedy which I can apply in order to manage these environmental triggers would be to remove Jim from this situation – to distance him from the angry principal, and to distance him from the academic setting. 3. Interactional/situational factors. These are factors which include poor communication between the patient and the faculty and the child’s parents (Duxbury and Whittington, 2004). Lack of listening skills is also a trigger to the child’s expression of aggression. The other students calling out to him are also situational triggers for the patient in this case. The appearance of the paramedic itself may be considered a trigger for aggressive behaviour in this case because it has put Jim on the offensive, threatening his ego and further feelings of insecurity. In order to eliminate this risk, I can remove Jim from this setting where he feels like a failure. I can bring him to the mental health institution or even just to the ambulance, in order to remove negative reminders for Jim. Question 2 When you talk with a calmer Jim he admits that he has thought about suicide. The NSW Department of Health guidelines for suicide risk assessment recommend use of a ‘hierarchy of questions’. Explain what is meant by the term ‘hierarchy of questions’ when exploring degree of suicide risk. Provide examples of dialogue you would use with Jim to explore his degree of suicide risk when using the principle of the 'hierarchy of questions'. The hierarchy of questions as provided by the NSW Department of Health (2004) are a series of questions which gradually and gently leads towards queries on suicidal ideas. It is a series of questions which help provide a clear idea for the health professional on the thoughts and the ideation of the patient. It helps formulate patterns and thoughts which the patient may have in relation to his feelings and where such feelings may lead. These questions usually start with general questions which casually evaluate how the patient is living his life and his current circumstances and plans for the future (Jones, 2004). More specific questions would then be fashioned based on the initial general questions. These questions will mostly focus on the patient’s feelings of hopelessness and helplessness. Such questions would also detect suicidal plans of the patient, and if their feelings of worthlessness and hopelessness have led them to plans of harming themselves or eventually committing suicide (Jones, 2004). In asking these questions, the main concern of the clinician, or in this case, the paramedic would be the safety of the patient. These questions, as much as possible, must be carried out away from the patient’s home, or in places where the patient’s safety is at risk (NSW, 2004). It must therefore be carried out in places where assistance can be made readily available for emergency care. Additional staff must also be available in order to ensure the patient’s safety. The hierarchy of questions are designed to evaluate the patient’s demeanour and thought processes based on his current circumstances and emotions. While posing these questions on the patient or in instances when the patient would not be immediately assessed for suicide risk, proper observation and supervision of the patient is an essential part of mental health care (NSW, 2004). These observations would help detect changes in the feelings of the patient which may border on suicidal with a strong desire to carry it through. Questions: How have you been lately? How bad have things been for you? Do you think it would get better? Or get worse for you? How did the exam failure make you feel? Do you think you can make up for your failure? Has the failure make you feel very bad about yourself? Has it made you feel sad and worthless? Has it made you depressed and helpless? Do you think your failures define you as a person? Do you think other people see you as a failure? Has your failure made you feel like harming yourself? Have you tried harming yourself before due to bad feelings? Have you succeeded in harming yourself? Did harming yourself make you feel better? Are planning to commit suicide? Have you already made plans on how and when to commit suicide? Do you have any harmful weapons or objects you are planning to use? Are you determined to commit suicide as soon as you find the opportunity? Question 3. You also contact the Community Mental Health Team. Jim's case manager is not available and you speak to another mental health team member who is not familiar with Jim's case. They ask if there is any evidence that Jim is psychotic. Give your answer based on your assessment with reference to the DSM criteria and definition for psychosis and only using information about Jim’s behaviour and thinking provided in the case study. Why is it important to find out if Jim is psychotic? In what ways could it increase risk of self harm? I believe that Jim is not psychotic. Jim does not manifest evidence based on the DSM criteria and the definition of psychosis to support psychosis. Instead, he has Borderline Personality Disorder because he exemplifies the following symptoms which fit the DSM criteria for the disorder: pervasive pattern of emotional instability, poor impulse control, disturbed self-image, unstable moods, impulsive aggression, chronic suicidality, repeated self-injury, and interpersonal chaos (Scanlan and Purcell, 2009). Although normally adolescents display these behaviours as part of their physiological development, the number and pervasiveness of the issues distinguishes Jim’s symptoms from normal adolescence behaviour. His reported repeated suicide attempts and self-harming behaviour as well as his erratic behaviour and displays of self-harm and aggression indicate that his symptoms show more than normal adolescent behaviour. But they indicate a personality disorder not a psychosis. He also manifests other behaviour which strongly support a diagnosis of BPD including his being emotionally reactive and active, being uninhibited, being unstable in terms of shifting baseline moods to depression and anxiety, expressing inappropriate and intense anger, including lack of control over anger (Sperry, 2003). Psychosis refers to a group of disorders which manifest with a loss of contact with reality. These individuals usually suffer hallucinations and delusions which is very much far removed from reality (Ehmann, et.al., 2004). Psychosis also manifests with gross excitement and overactivity, grandiosity, catatonic behaviour, and marked psychomotor retardation. These qualities are not seen in the patient, and this disqualifies him from such a psychotic diagnosis. Psychosis may also be apparent in diseases like schizophrenia, affective disorders like depression or mania in bipolar disorder, schizoaffective disorder, delusional disorder, obsessive compulsive disorder, and some personality disorders, including borderline personality disorder (Gelder, 2005). It is important to establish if Jim is not psychotic because it would immediately entitle him to a different type of mental health care. Classifying Jim as psychotic would mean that he would be cared for as a mental health patient with delusions or any other psychotic features (WHO, 2008). Instead, his admission to mental health care would be for BPD, not psychosis. This would also entitle him to be thoroughly assessed for mental illness, and later to be treated as a mental health patient. The diagnosis of BPD would also reduce the risk of self-harm as it would make the patient a candidate for suicide watch (Barratt and Pool, 2008). He would have to be watched 24 hours a day, and 7 days a week by a mental health professional until his suicide risk would be reduced or eliminated. As a mental health patient, he would be entitled to therapeutic assistance which would help him deal with his feelings and his symptoms, helping him later to reintegrate into society and fulfil his normal activities as a productive individual. Question 4. Having completed a mental status assessment you will now have to decide what further action you should take. Using the CTRS (Crisis Triage Rating Scale) in conjunction with the four questions which it has been suggested in the subject material that you use as a guide for making Section 20 decisions explain what type of follow up Jim needs and whether Section 20 would be justified? You note his case manager is not likely to be available until Monday. Jim needs interventions which prevent self-harm. He needs to be watched constantly in order to prevent any more attempts at suicide or self-harm. His follow-up care includes therapy to manage his impulsiveness, as well as his aggressiveness and anger. Follow up on his mental status in relation to the failure in his exams has to be undertaken in order to assess his coping and the management of his emotions. Based on the Crisis Triage Rating Scale, his risk is emergent, meaning there is acute decompensation with a child or other individuals being at risk. The person is going through a psychotic episode and is suicidal. The objective in the management of this patient would be to control, de-escalate, stabilize, and offer treatment. Process and resources needed has to include police involvement, medical emergency requiring hospitalization, or admission to a mental health institution. If the patient would not be admitted, a contract for his safety and follow-up would have to be made with him and/or with other individuals charged with his care. Since this patient has no immediate available support system that can assist in his mental care, he would have to be admitted to the mental health institution. Although his suicidal thoughts or self-harming behaviour may be quelled and dismissed when he expressed that he was okay and did not need any medical help, his impulsiveness may still cause him to act in a self-destructive way. There are facets of his mental illness and risk qualities which imply the need for admission to a mental health facility, atleast until his mental health can be managed appropriately and when he no longer poses a threat to himself and to others. Using the CTRS system is appropriate because it helps assess if the patient needs to be hospitalized or is need of an intervention which would manage his current symptoms. The CTRS is a scale which assesses the patients and their dangerousness, their support systems, and the motivation and cooperation (Cornwall General Hospital, 2003). This system helps assess the behaviour which Jim is manifesting. Jim scored 4 on the dangerousness scale which represents some suicidal ideation or behaviour, or history of the same, but clearly wishes is under control. This is dangerous because Jim already has had a history of self-harming behaviour; and the next time he would harm himself might be the last time (Cornwall General Hospital, 2003). Jim rates as 2 in the support system because some support system may be mobilized, but its effectiveness is limited. Support system from his Case Manager cannot currently be mobilized because of unavailability, and it can also be mobilized through his mother, but the latter is not also available (Cornwall General Hospital, 2003). As for his ability to cooperate, he is unable to cooperate and actually actively refuses to cooperate. He insists he is already okay and does not need medical help. This is a dangerous declaration because he may still have suicidal thoughts. After totalling results, Jim scores a 7 in the CTRS scale. This indicates an emergent risk. In a discussion by Barling, (2009) he expressed that a score of below 9 in the CTRS scale manifests a need for hospitalization, a score above 9 requires another intervention. This score therefore supports the decision to transport Jim because his score of below 9 indicates a significant risk – one which requires hospitalization. Because of the situation, paramedics are following protocol S3, the protocol used in dealing with mental health patients. Jim has to either voluntarily go to the hospital or involuntarily under Section 20 of the Mental Health Act. After evaluating his condition, Section 20 can be applied to him. Section 20 basically establishes that an ambulance officer may take a person to a mental health facility, where he sees reasonable grounds for mental illness or disturbance in a person and where it would prove beneficial to a person. He may further call for police assistance if he has serious concerns about the safety of the patient or other individuals if the patient would be taken to the mental health institution without the assistance of a police officer (Mental Health Act, 2007). As a paramedic reviewing Jim’s condition, I believe that he needs to be admitted to the nearest mental health facility. He poses an emergent danger to himself and to other people and he qualifies under Section 20 for “Detention on information of ambulance officer”. The fact that Jim does not have a readily available support system, as in parents or guardians, makes him a significant risk for suicide or self-harm. Moreover, the fact that he is homeless, living in a hostel, being mentally managed by a Case Manager, who is also not available, makes his case particularly dire. He therefore needs admission in a mental health facility in order to prevent any self-harming behaviour and to sufficiently manage his mental health care. Question 5. You note that Jim has a diagnosis of Borderline Personality Disorder which is categorised under Cluster B of the Personality Disorders in the DSM. Describe what Cluster B means and discuss the main characteristics typical of BPD and the family history and patient needs often associated with this disorder. From the scenario description does Jim evidence any of these characteristics? Cluster B personality disorders are disorders which include antisocial, borderline, histrionic, and narcissistic personality disorders (National Drug Strategy, n.d). According to Elder, et.al., (p. 291) “childhood abuse or other trauma that may result in low self-esteem or even self-loathing often appears in the histories of many people with Cluster B disorder”. Individuals who suffer from this mental disorder often manifest dramatic, erratic, and emotional behaviour (National Drug Strategy, n.d). Among those who suffer from antisocial personality disorder, a pattern of disregard for and a violation of the rights of others mostly manifest. For those with histrionic personality disorder, the patient manifests patterns of excessive emotionality and attention-seeking behaviour. For those with narcissistic personality disorders, they manifest feelings of grandiosity, a need for admiration, and a lack of empathy (National Drug Strategy, n.d). Those with borderline personality disorders, they portray patterns of instability in their interpersonal relationships, and in their self image; they are also markedly impulsive (National Drugs Strategy, n.d.). Borderline personality disorder is a complicated and serious mental illness which includes different symptoms and maladaptive behaviour (Mental Illness Fellowship Australia, 2009). It is termed borderline because this disease is said to lie between the bounds of psychotic and neurotic mental diseases. This disease is primarily characterized by the immediate efforts made to avoid what is perceived to be abandonment, as well as long-standing issues with relationships and a person’s self identity (Mental Illness Fellowship Australia, 2009). Suicide rate in Australia for people who suffer this disease rises up to almost 10%. This disease is characterized by symptoms mentioned earlier. To recap, they include: poor regulation of emotions, harmful impulsive actions, distorted perceptions and impaired reasoning on issues, markedly disturbed relationship, are unable to provide self-comfort. Their history is often marked with childhood temperament or predisposition, child abuse, childhood neglect, family disintegration and similar childhood disruptions (Mental Illness Fellowship Australia, 2009). As was already previously assessed, Jim manifests many of these symptoms which denote a borderline personality disorder. He has practically been abandoned by his mother who has her own mental health issues and is ambivalent about her feelings in relation to her son. Jim is also homeless and is practically living a life in the streets, if not for the hostel that he is living in. He has experienced much upheaval in his teenage life and his history seems to manifest that this upheaval has been present since his childhood days. His current mental illness is very much linked with his childhood and the disruptions in his childhood. His relationship with other people, most especially his mother is disturbed and he does not seem capable of handling his emotions. His coping mechanisms are severely affected and this can be seen in his inability to cope with failures and disappointment. Reports of repeated self-harming behaviour also indicate erratic and impulsive behaviour. Locking himself in the science laboratories further manifest impulsivity. Considering all these qualities, I am inclined to believe that Jim has Borderline Personality Disorder. The discussion above indicates that paramedics have to apply care and caution in dealing with mental health patients like Jim. The legal and clinical standards of care and transporting of mental health patients have to be thoroughly reviewed and scrutinized in order to gain accurate data on the patient, including his family, and his support system. In instances when Section 20 of the Mental Health Act would be applied, the patient’s condition must be assessed in order to fit the patient’s circumstances and to ensure that the best decision is being made for him. It is therefore important for paramedics to apply critical analysis in their actions in mental health situations. Reference Barling, J. (2009). Assessment and diagnosis. In Elder, Evansky & Nizette, Psychiatric and Mental Health Nursing (pg 160 – 164). Sydney: Mosby. Barratt, M. & Pool, S. (2008). Principles of Clinical Medicine for Space Flight. Sydney: Springer. Citrome, L. (2011). Aggression. Retrieved 15 September 2011 from http://emedicine.medscape.com/article/288689-overview Cornwall General Hospital (2003). Mental Health Crisis Response Protocols. Retrieved 15 September 2011 from http://www.pmhl.ca/webpages/reports/Protocols1.pdf Department of Health New South Wales (2004). Framework for Suicide Risk Assessment and Management for NSW Health Staff. Retrieved 15 September 2011 from http://www.health.nsw.gov.au/pubs/2005/pdf/suicide_risk.pdf Duxbury, J. & Whittington, R. (2004). Causes and management of patient aggression and violence: staff and patient perspectives. 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Retrieved 15 September 2011 from http://www.mifact.org.au/media/mif/images/factsheets/understanding/UBorderlinePersonalityDisorder.pdf National Drug Strategy (n.d). Personality disorders and substance use. Department of Health. Retrieved 15 September 2011 from http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/m718.pdf Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. Sydney: Routledge. World Health Organization. (2008). Integrating mental health into primary health care: a global perspective. Switzerland: World Health Organization. Read More