Organic causes of anxiety symptoms \200 Neurological (epilepsy, dementia, head injury, CVA, brain tumor, MS, Parkinson \200\231s di sease). Pulmonary (COPD, asthma, airway-assisted patients on weaning trials). Cardiac (arrh ythmias, heart failure [CHF], angina, mitral valve prolapse). Hyperthyroidism, hypoglycaemi a, metabolic acidosis/alkalosis, phaeochromocytoma. Medications (antidepressants, antihyper tensives, antiarrhythmics). Drugs of abuse (alcohol, BDZs, caffeine, cannabis, cocaine, LSD , ecstasy, amfetamines). \200 \200 Key points in assessment \200 Assess for medical causes for symptoms \201 rst. Has the Medical work-up patient had a co mplete medical evaluation for the physical complaints? Consider substance abuse/ingestion A lways take a drug/alcohol history, and selected patients should have urine drug screen. Pas t psychiatric history disorder that is being made worse by a new medical stressor? ? Do the subjective match the Are there psychological anxiety symptoms objective \201 ndings? Doe s the patient feel like or fear they are going to die? Have a sense of doom? Fear they are going crazy? Does the patient have an underlying anxiety 19_Semple_Chap19.indd 781 12/7/2012 4:30:26 PM CHAPTER 19 Liaison psychiatry 782 Assessment of psychotic symptoms and confusion Psychotic symptoms While referrals for asses sment of apparent psychotic symptoms are com- mon in the general setting, presentations wit h functional psychoses are rare in comparison with psychiatric hospitals. They are seen in the emer- gency department, in patients brought in by police to a \200\230place of safety \200\231 and after self-harm (especially in those using violent or bizarre methods). Howeve r, in the majority of cases in the general hospital psychotic fea- tures represent organic illnesses \200\224commonly delirium, or are part of a withdrawal syndrome. Differential diagnosis Delirium (b p. 790), drug intoxication or withdrawal, alcohol withdr awal, epileptic phenomena (b p. 156), dementia (b p. 132), schizophrenia (b p. 178), acute/ transient psychotic disorders (b p. 226). Organic causes of psychosis \200 Neurological (epilepsy, head injury, brain tumor, dementia, encephalitis, e.g. HSV, HIV, ne urosyphilis, brain abscess, CVA). Endocrine (hyper/hypothyroidism, Cushing \200\231s, hyper parathyroidism, Addison \200\231s disease). Metabolic (uraemia, electrolyte disturbance, po rphyria). SLE ( \200\230lupus psychosis \200\231). Medications (steroids, levodopa (L-dopa) , interferon, anticholinergics, antihypertensives, anticonvulsants, stimulants). Drugs of a buse (cocaine, LSD, cannabis, PCP, amfetamines, opioids). \200 \200 Key points in assessment \200 The nature of any hallucinations characteristic of functional psychoses, while visual hallu cinations (and visual illusions and misperceptions) are seen in organic conditions. Presenc e of \202 uctuations Note whether symptoms are \202 uctuating in nature or associated w ith confusion and/or behavioral disturbance. A waxing and waning picture with alterations i n attention and alertness suggest delirium as opposed to a primary psychotic disorder. Prev ious history previous or current history of drug or alcohol use. Time course of illness pre sent? Was there a gradual or sudden onset? Have previous similar episodes occurred before? Vital signs symptoms. It is helpful to look for any autonomic instability, vital sign chang es, sweating, and tremor which may suggest an underlying withdrawal from alcohol or other s edatives. Such changes would be less likely in a primary psychotic disorder. Auditory hallucinations are Note any previous history of psychotic illness or How long have psychotic symptoms been Withdrawal syndromes can present with psychotic 19_Semple_Chap19.indd 782 12/7/2012 4:30:26 PM ASSESSMENT OF PSYCHOTIC SYMPTOMS AND CONFUSION 783 Confusion A common referral is the request to assess for the severity and possible cause of confusion. A wide range of disorders and insults to the brain produce three common clinica l presentations: (1) acute confusional state or delirium, (2) dementia (progressive or non- progressive), and (3) acute or chronic confusion. A common question is the extent to which a confu- sion re \202 ects acute or chronic de \201 cit \200\224often linked to requests for opin- ion about capacity/consent and placement issues. Another key question is whether there is a reversible component to the condition. Differential diagnosis Delirium (b p. 790), dementia (b p. 132), alcohol withdrawal, drug i ntoxication or withdrawal, Wernicke \200\223Korsakoff syndrome, epileptic phe- nomena, func tional psychoses. Key points in assessment \200 Bedside cognitive testing orientation in time, place, and p erson, and make an objective measurement of confusion (e.g. AMT, MMSE, ACE \200\224 b p. 70 ). Previous history For an accurate account of the previous history in a confused patient i t is vital to have corroboration of the patient \200\231s account \200\224this should ideal ly be by a live-in or close relative or friend, but in their absence a neighbor or GP may p rovide useful information. Note any previous history of cognitive impairment or functional decline; any history of alcohol of drug use; and any history of previous similar episodes. Previous functional level cognitive de \201 cit now, and the level of cognitive function o ver the lifespan, re \202 ected in the educational achievement of the patient and their wo rk status, and their recent cognitive function as re \202 ected in their self-care, etc. M edical status records and nursing notes/observations. Note recent investigation \201 ndin gs, noting particularly any abnormal results or recent changes. Examine drug kardex for any medications associated with confusion \200\224 have any medications recently been started or stopped? Consideration of specialist testing neurocognitive assessment may be helpful. C onsideration of imaging colleagues, consider whether cerebral imaging (e.g. CT, MRI) is ind icated. Assess conscious level (via GCS \200\224 b p. 69), It is important to consider the degree of Note current medical condition as recorded in the case In selected cases specialist In consultation with medical and radiology 19_Semple_Chap19.indd 783 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 784 Parasuicide assessment Parasuicide is a deliberately undertaken act which mimics the act of suicide but does not result in death. Psychiatric assessment of such patients is mandatory once their medical condition allows. The involvement of men- tal health professionals in t he assessment of patients following parasuicide relates to the following observations: \200 In this population of patients, roughly 1% will die by completed suicide in the 24mths afte r the initial parasuicidal act, with the risk highest in the weeks following the original a ct. This represents a mortality by suicide 50 \200\223100 times that of the general populat ion. The rates of completed suicide are signi \201 cantly raised in all mental disorders e xcepting mental handicap and dementia. Studies examining completed suicides in patients wit h mental illness show inadequate doses of therapeutic drug treatment, increased dropout rat e from follow-up and increased presence of untreated comorbidity. Clear risk factors exist for completed suicide (see Box 19.1) and the closer the parasuicidal patient approximates t o these demographics, the greater the relative risk. However, the absolute risk is low and estimate of the risk in a particular case relies on assessment of the individual act and th e mental state. Assessment The initial management of the patient following overdose or other deliberate sel f-harm will be by specialist toxicologists or general medical/surgical specialists. Early p sychiatric assessment may be required for advice regarding detainability, behavioral distur bance, drug/alcohol withdrawal, or delirium, but assessment of the parasuicide itself shoul d be deferred until conscious level is full. The history should focus on the act itself, th e patient \200\231s mental state and recent life events, and past medi- cal/psychiatric his tory. It may be easier to assess these in reverse order, moving from the factual history to wards the emotive descriptions of the parasuicidal act itself after building rapport. Features of act \200 Method making up most of the remainder. Use of method likely to be f atal (e.g. jumping, hanging) is indicative of clear intent to die. Patient \200\231s belief in the lethality of the method Did the patient believe that that combination of tablets wa s likely to be fatal? Serious suicidal intent is associated with medically trivial overdose s \200\224and vise versa. Length of planning moment \200\231, or planned in advance \200 \224and for how long? Triggers they intoxicated at the time? Was there any direct \200\230 gain \200\231 (e.g. patient in custody at the time of act)? Final acts Was there a suicide note? Did they make any other \200\230acts of closure \200\231 (e.g. setting affairs in or der, arranging for the care of children)? Precautions to avoid discovery Would they have an ticipated being found? Did they signal or tell their intentions to another? Was anyone else actually present at the time? 90% of parasuicides are by self-poisoning with self-cutting Was the act impulsive \200\224 \200\230on the spur of the Was there a clear precipitant (e.g. row with partner)? Were Where did the act take place? 19_Semple_Chap19.indd 784 12/7/2012 4:30:27 PM PARASUICIDE ASSESSMENT 785 Previous similar acts Are there any different features? Actions after act up coming to hosp ital? Is this act a repeat of a previous non-fatal act? What did they do after the act? How did they end Mental state \200 Attitude now to survival alive? Do they have ongoing wish to die? How do they feel about th e future and what plans (if any) do they have? Affective symptoms Current affective symptom s. Recent symptoms of low mood, anhedonia, and hopelessness. Biological depressive features . Substance misuse problems misuse or dependence. Other mental disorder mental disorder as directed by the history. Risk to others Did the parasuicidal act put anyone else at risk? Are they relieved or disappointed to be Evidence for current drug or alcohol Enquire directly about other symptoms of Is there any evidence of intent to harm anyone else? Personal and past medical/psychiatric history \200 Recent life events (e.g. bereavements, job loss, relationship break-up). Current life situa tion and security of job and accommodation. Presence of legal/criminal problems. Previous o r current psychiatric diagnoses records if further details required or if signi \201 cant history. Physical health problems Describe recent events involving loss or change State of current signi \201 cant relationships. Type Clarify with hospital Again clarify with records or GP if required. Box 19.1 Risk factors for completed suicide Sociodemographic factors \200 \200 \200 \200 \200 Male sex. Elderly. Single, divorced, or widowed. Living alone, poor social support. Unemplo yed or low socio-economic class. Personal/mental health factors \200 \200 Previous parasuicide or DSH. Any mental disorder (greatest risk in major depression and ano rexia nervosa, then functional psychosis, then neurotic and personality disorders). Depende nce on alcohol or drugs. Recent inpatient psychiatric treatment. Concurrent physical disord er. Recent bereavement. \200 \200 \200 19_Semple_Chap19.indd 785 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 786 Management after parasuicide Reasons for act Only a minority of patients presenting after p arasuicide have evidence of clear intent to die. Assessment will reveal a mixture of the fo llowing types of case: \200 Those whose intent was unequivocally to die but were prevented by discovery, chance, or ove restimation of the lethality of the method. Those who were ambivalent whether they lived or died, \200\230letting the chips fall as they may \200\231. Those whose act was impulsive and \200\230in the heat of the moment \200\231 in response to an immediate stressor. Those whose actions were designed to communicate distress \200\224the classical \200\230cry for help \200\231. Those whose actions were manipulative in nature and designed to provoke cha nged behavior from others. Those attempting to escape from intolerable symptoms or an intol erable situation. Those whose intent is later unclear even to themselves. There may initially be diagnostic confusion with the following groups: (1) deliberate overd oses of drugs taken for intoxicating effect; (2) deliberate self-harm (e.g. wrist cutting) which is a repetitive, ritualistic action whose intent is to relieve tension, not to kill o r seriously injure; (3) accidental overdoses of prescribed or OTC medication. (1) and (2) m ay merit psy- chiatric evaluation in their own right and (3) should be examined carefully f or evidence of post hoc rationalization of a parasuicide. Assessment aims By the end of ass essment you should aim to answer the following questions: \200 Is there ongoing suicidal intent? to die; ambivalence about survival; sense of hopelessness towards future; clear intent to die at time of act. Is there evidence of mental illness? D iagnosed in the normal way. Most common diagnoses are depressive illness and alcohol misuse . Be alert to comorbid substance misuse and to the combination of an acute stressor on the background of a chronic condition. Many Are there non-mental health issues which can be add ressed? patients will reveal stressors such as: family or relationship dif \201 culties; e motional problems (particularly relating to previous abuse; school or employment problems; debt; legal problems; problems related to immigration). They can be usefully directed to ap propriate local services. Evidenced by: continuing stated wish Management \200 In many cases this will be managed by Ongoing suicidal intent admission to a psychiatric ward, on a compulsory basis if necessary . Mental illness \200 Patients already known to mental health services Here close liaison with the usual team is required to agree a joint management plan. New diagnoses appropriate service for follow-up, rather than necessarily starting Here the focus should be on integrating with an 19_Semple_Chap19.indd 786 12/7/2012 4:30:27 PM MANAGEMENT AFTER PARASUICIDE 787 new treatments. The type of appropriate follow-up depends on the type of disorder (e.g. GP review for moderate depressive illness, referral to alcohol services for alcohol abuse). Sh ort-term community outreach from liaison psychiatry can \200\230bridge \200\231 the patien t to the general services. Try to ensure follow-up is as soon as possible, even if non-urge nt, as otherwise non-attendance is very high. Admission required admission will sometimes b e indicated after parasuicide even where there is no ongoing suicidal intent. This may be d ue to seriousness of condition (e.g. new psychotic illness) or to allow for a period of inp atient assessment of mental state. It should not simply be in order to defer or devolve the decision about discharge \200\224ask yourself what will have changed to mean discharge in a few days will be safer than now. For both new and established mental illnesses, Other issues appropriate agency (e.g. abuse counseling service, school counselor). Clarify the appropriateness of the referral and referral method and feed these back to the patient. In all cases cases discuss with GP (mandatory if GP input is required). Consider provision of emergency crisis card giving details of emergency psychiatric service and telephone con tact for emergency counseling/ support services. With the patient \200\231s permission discuss the case with an Discuss and agree management plan with patient. In most Frequent attenders A small minority of patients attend emergency services repeatedly with p arasuicidal acts or deliberate self-harm without suicidal intent. A management plan for suc h patients should be agreed on a case-by-case basis. The aim should be to avoid \200\230re warding \200\231 maladaptive behaviors (e.g. by repeated admissions providing \200\230time -out \200\231 from stressful situations), while providing appropriate support and treatment . 19_Semple_Chap19.indd 787 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 788 Depression in physical illness Depressive illness is more common in those with physical ill ness than in the healthy population. In primary care the prevalence of depressive illness i s 5%, while in medical outpatients it is 5 \200\22310% and in medical inpatients it is 10 \200\22320%, with higher rates reported in some studies. The frequency of depressive illnes s is raised in those with more severe illnesses, and some conditions (e.g. cardiac and neur ological disorders) show very high rates. Occurrence of depression in physically ill patien ts adds to their morbid- ity, both due to the depressive symptoms themselves, and by hamper ing the treatment of the underlying medical condition (e.g. by impairing com- pliance or by diminishing interest in rehabilitation). Additionally there is increased risk of cardiac m ortality in depressed patients, which is directly correlated with the severity of the depre ssion. Depression is poorly recognized and undertreated in general patients. In some medical setti ngs there is a lack of focus on psychiatric symp- toms \200\224 \200\230not willing to ask the question \200\231. There is also often a reluctance to prescribe antidepressants in con text of medical illness. More often the possibility of treatment is simply overlooked with the patient assuming that the symptoms are due to their underlying disorder and the treatin g physician making assumptions (e.g. \200\230I \200\231d be depressed in his situation \200\231) and not thinking of offering treatment. Reasons for the association of depression and physical illness \200 The physical illness causes the depression: \200 Biological cause \200\224e.g. hypothyroidism, Cushing \200\231s disease, Parkinson \200\231 s disease. Psychological cause \200\224related to loss or change, life events secondary to illness, e.g. amputation, loss of sexual function. Particularly potent are fatal or potenti ally fatal, dis \201 guring, or disabling diseases. The depression is a side-effect of the treatment for the physical illness: \200 B-blockers, digoxin, calcium Drug treatments, e.g. steroids, channel blockers, aminophylline, theophylline, NSAIDs, cime tidine, metoclopramide, levodopa, methyldopa, isotretinoin, A interferon. Dis \201 guring, painful, or prolonged treatments. The physical illness is a result of the depression \200\224e.g. liver failure after paracet amol overdose in context of depressive relapse. The physical illness and the depression hav e a common cause \200\224e.g. stressful life events acting as precipitants to both MI and d epression. Their co-occurrence may be coincidental \200\224depressive illness is common and its co-occurrence with other common illnesses can be expected by chance. Presentations of depression in physical illness Low mood, tearfulness, hopelessness regardi ng recovery, biological depressive features (poor sleep, appetite, energy, and concentratio n) \200\224 which may be misinterpreted as symptoms of the physical disorder, poor complian ce, increase in somatic complaints or complaints of pain severity, apparent cognitive impai rment (pseudodementia). 19_Semple_Chap19.indd 788 12/7/2012 4:30:27 PM DEPRESSION IN PHYSICAL ILLNESS 789 Diagnosis Nursing staff are often more pro \201 cient than medical colleagues at identify- ing medical inpatients with depressive disorders. While operational diag- nostic criteria are the same in physically ill as in physically well patients, biological features may be l ess useful in making the diagnosis. Features: \200 Depression of mood (is it pervasive or do some activities \200\224e.g. family visits \200 \224still provide pleasure?) Hopelessness (is the patient \200\231s attitude that although things are bad now they can still look forward \200\224e.g. to going home, to moving to the rehab ward, or are they hopeless about any prospects for recovery?) Morning depression (do the nurses note a diurnal variation in mood, or in other marker symptoms, e.g. interest in rehab, talkativeness?) Screening tools are available (e.g. Geriatric Depression Scale) and are used in some center s. They do not replace individual clinical assessment. Treatment (see also b pp. 256 \200 \2239) Effective treatment offers the possibility of improvement in mood (which is of cours e valuable in itself) but also improved rehabilitation, better com- pliance, decreased hosp ital stay, and an overall reduction in morbidity, mortality, and eventual disability. \200 Practical interventions of prognosis, about which the patient may be unduly pessimistic); a ttempt to improve social contacts; aim to optimize medical condition, mobility, and pain co ntrol. Psychological support : often the liaison psychiatrist will have a key role here, bu t you should also attempt to engage the nursing and paramedical staff in supportive psychot herapeutic interventions \200\224often these staff members are enthusiastic about construct ive involvement but fearful of \200\230doing the wrong thing \200\231, and will appreciate your guidance. Consideration of drug treatment: those in patients without medical illness while taking note of the advice given for treatment in speci \201 c medical conditions (b pp. 968 \200\22379). Speci \201 c psychological treatments: individual psychotherapy is of ten unavailable in or unsuited to the general setting, but some therapies, e.g. CBT, are no w incorporated into rehabilitation and pain management programs. : e.g. attention to speci \201 c worries (e.g. clari \201 cation treatment strategies are similar to 19_Semple_Chap19.indd 789 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 790 Acute confusional state (delirium) Essence Stereotyped response of the brain to a variety o f insults, very commonly seen in hospital inpatients. Syndrome characterized by acute onset of \202 uctuating cognitive impairment (or deterioration in pre-existing cognitive impai rment) associated with behavioral abnormalities. Like other acute organ failures it is comm oner in those with chronic impairment of that organ (e.g. dementia, may be undiagnosed). Epidemiology inpatients (10 \200\22320%). in medical and surgical Extremely common Particul arly vulnerable include: elderly; pre-existing dementia; blind or deaf; very young; post-op erative (especially cardiac); burn victims; alco- hol- and benzodiazepine-dependent; seriou s illness, particularly multiple. Carries signi \201 cant mortality, as well as morbidity to patient and others. Common cause of delayed discharge. Clinical features \200 \200 Impaired ability to direct, sustain, and shift attention. Global impairment of cognition wi th disorientation, and impairment of recent memory and abstract thinking. Disturbance in sl eep \200\223wake cycle with nocturnal worsening. Psychomotor agitation. Emotional lability. Perceptual distortions, illusions, and hallucinations \200\224characteristically visual. S peech may be rambling, incoherent, and thought disordered. There may be poorly developed pa ranoid delusions. Onset of clinical features is rapid with \202 uctuations in severity ov er minutes and hours (even back to apparent normality). \200 \200 \200 \200 \200 Three clinical presentations are commonly seen, distinguished by differing combinations of symptoms: hyperactive or agitated delirium (psychomotor agitation, increased arousal, inapp ropriate behavior, delusions, and hallu- cinations); hypoactive delirium (psychomotor retar dation, lethargy, excess somnolence); and mixed delirium (combination of these features wit h vary- ing presentation over time). Differential diagnosis Mood disorder; psychotic illness (new major mental disorder very muc h less likely than delirium in a hospitalized patient, particularly if elderly); post-ictal ; dementia (characteristically has insidious onset with stable course and clear consciousne ss). Etiology The cause is frequently multifactorial and the most likely cause varies with the c linical setting in which the patient presents: \200 Infective bacterial endocarditis (SBE). UTI; chest infection; wound abscess; cellulitis; subacute 19_Semple_Chap19.indd 790 12/7/2012 4:30:27 PM ACUTE CONFUSIONAL STATE (DELIRIUM) 791 Metabolic uraemia; cardiac failure; hypothermia. Intracranial tumor; raised ICP. Endocrine hypoglycaemia; diabetes mellitus; vitamin de \201 ciencies. Substance intoxication or with drawal anticholinergics; psychotropics; lithium; antihypertensives; diuretics; anticonvulsa nts; digoxin; steroids; NSAIDs. Secondary to any cause. Hypoxia Anemia; electrolyte disturbance; hepatic encephalopathy; CVA; head injury; encephalitis; primary or metastatic Pituitary, thyroid, parathyroid, or adrenal diseases; Alcohol; BDZs; Course and prognosis Delirium usually has a sudden onset with a \202 uctuating clinical c ourse thereafter. There is gradual resolution of symptoms with effective treat- ment of the underlying cause. Symptom resolution may be much slower in the elderly. There is often pat chy amnesia for the period of delirium following recovery. Mortality is high ( 20% of patie nts will die during that hospital admission, up to 50% at 1yr). May be a marker for the sub sequent development of dementia. Assessment (see also b p. 782) \200 Attend promptly (situation only tends to deteriorate and behaviourally disturbed patients c ause considerable anxiety on medical wards). Review time course of condition via notes and staff report \200\224note recent investigation \201 ndings, particularly any abnormal res ults or recent changes. Examine kardex for any drugs associated with confusion \200\224have any medications recently been started or stopped? Establish premorbid functional level (e. g. from relatives or GP). Management Four main principles of management: \200 Identify and treat precipitating cause and exacerbating factors. \200 Likely primary cause varies according to setting and examination \201 nding \200\224remem ber cause may be multifactorial. Optimize patient \200\231s condition \200\224attention to hydration, nutrition, elimination, pain control. Provide environmental and supportive measures. \200 \200 \200 Education of those who interact with the patient. Make environment safe. Create an environm ent which optimizes stimulation \200\224e.g. adequate lighting, reduce unnecessary noise, m obilize patient whenever possible, and correct any sensory impairment (e.g. hearing aids, g lasses). Reality orientation techniques. Firm clear communication, preferably by same staff member (or small group of staff). Use of clocks and calendars. Avoid sedation unless severely agitated or necessary to minimize risk to patient or to faci litate investigation/treatment. \200 \200 Use single medication, start at a low dose and titrate to effects. Give dose and reassess i n 2 \200\2234hrs before prescribing regularly. 19_Semple_Chap19.indd 791 12/7/2012 4:30:27 PM CHAPTER 19 Liaison psychiatry 792 Consider oral haloperidol 0.5 \200\2231mg up to max of 6mg daily, oral lorazepam 0.5 \200 \2231mg up to max of 4mg daily, or oral risperidone 1 \200\2234mg up to max of 6mg daily \200\224consider giving preference to antipsychotic management in the \201 rst instance, benzodiazepines tend to worsen delirium with the exception of alcohol withdrawal and gammab utyrolactone (GBL) withdrawal. For delirium related to alcohol withdrawal, BDZs are the dru gs of choice \200\224see b p. 560. Review dose regularly and aim to stop as soon as possibl e. \200 Regular clinical review and follow-up (MMSE useful in monitoring cognitive improv ement at follow-up). 19_Semple_Chap19.indd 792 12/7/2012 4:30:27 PM This page intentionally left blank CHAPTER 19 Liaison psychiatry 794 Capacity and consent1 A fundamental principle of medical practice is that treatment of a pa tient should be with their valid consent. Valid consent is that which is informed, freely g iven, and obtained from a patient with capacity. The medical team will often ask for a psyc hiatric opinion as to a patient \200\231s capacity to make treatment decisions. While all d octors should be familiar with assessment of capacity and be prepared to make decisions reg arding consent, liaison psychiatrists are often consulted on such matters due to their expe rience in assessing mental disorder and abnormal mental states and their (usually) greater knowledge of applicable law. Incapacity legislation Speci \201 c incapacity legislation exists in England and Wales (th e Mental Capacity Act 2005 \200\224b p. 876), and Scotland (the Adults with Incapacity Act 2000 \200\224b p. 878). These Acts and their accom- panying codes of practice should direct and guide clinical practice relating to incapacity for doctors working in these jurisdicti ons. Referral types Occasionally, these referrals will take the form of a spe- ci \201 c questi on, e.g. does this patient with dementia have capacity to give consent to a hip operation? More often they re \202 ect a number of worries about a patient \200\231s capacity, abilit y to care for themselves, and decisions which balance a patient \200\231s autonomy against best exercising their duty of care. The two most common referrals ask the following questio ns: \200 Does this patient have the capacity to consent to or refuse consent for a procedure or trea tment? Does this patient have the capacity to make personal welfare decisions (e.g. to choo se to go home rather than accept residential care)? Occasionally a referral is phrased as a capacity assessment when the patient is seeking to leave hospital against medical advice and what is actu- ally required is a decision as to t he patient \200\231s detainability under the Mental Health Act. In these cases the patient should be assessed for the presence of mental disorder justifying detention in the normal w ay. In these cases remember that detention under the Mental Health Act does not allow for t he compulsory treatment of medical conditions. Assessment of incapacity 1. Identify the question The question \200\224 \200\230does this p atient have capacity? \200\231 is essentially meaningless. Incapacity law and common law in the UK presume capacity in adults, and incapacity law explicitly encourages the exercise o f residual capacity. Incapacity must therefore be assessed in relation to the particular de cision required of the patient and the nature of this decision should be estab- lished prio r to the interview. Additionally you should clarify with the medi- cal team what treatment is proposed, and what information has already been discussed with the patient. 2. Consider whether the patient has capacity to make the decision Incapacity cannot be pres umed on the basis of any individual patient factors (e.g. diagnosis of dementia, learning d isability, brain injury, mental disorder) 19_Semple_Chap19.indd 794 12/7/2012 4:30:28 PM CAPACITY AND CONSENT 795 but must be assessed speci \201 cally for each decision. The questions to ask are \200\224 for the decision required, does the patient have the ability to: \200 \200 \200 \200 \200 Make a decision? Understand the information relevant to the decision? Use or weigh that inf ormation in making the decision? Retain memory of the decision? Communicate the decision? For example, in considering whether a patient can refuse an amputation in the setting of os teomyelitis and early gangrene, we need to establish whether the patient is aware of the na ture of their illness, the treatment being offered to them, the risks and potential bene \201 ts associated with that treatment, and any alternative treatment options, as well as t he conse- quences of refusing treatment. 3. Evaluate the presence of psychiatric illness and determine whether it is in \202 uencin g the patient \200\231s decision Even if the patient \200\231s decision re \202 ects a fai r grasp of the elements of consent, it is necessary to determine whether their judgment is being in \202 uenced by mental illness. For example, if the patient with gangrene understa nds the nature of their infection and the risks of surgery versus delaying treatment, we wo uld not support their making a decision to avoid surgery if the decision was based on audit ory hallucinations telling them that they don \200\231t deserve to live. Therefore, a compr ehensive psychiatric assessment, screening for the presence of mental disorder, and includi ng an evaluation of how they have made their decision, is essential. The psychiatric evaluation for a capacity assessment needs to be com- prehensive, particula rly focusing on cognitive functions, reasoning and judgment; however, it is otherwise simil ar to any thorough psychiatric examination. The primary difference lies in the additional e xamination of how the patient has made similar choices in the past and what role psychi- at ric symptoms are playing in their current decision. 4. Gather additional information If the opinion is that the patient lacks capacity, then it will be important to establish: (1) what were the patient \200\231s views on the matter wh en greater capacity existed (e.g. did they discuss treatment outcomes with relatives?, is t here an advance directive?), (2) what are the views of the patient \200\231s rela- tives or carers?, is there a relative with surrogate decision-making powers (e.g. attorney, court-a ppointed deputy in England and Wales, or guardian in Scotland)? 5. Report and document opinion You should formally document your opinion and the reasons fo r it, as well as speaking to the treating team directly if at all possible. 1 This page should be read in conjunction with those pages in the Legal issues chapter desc ribing consent (b p. 870), treatment without consent (b p. 872), common law (b p. 874), and incapacity legislation (b pp. 876 \200\2239). 19_Semple_Chap19.indd 795 12/7/2012 4:30:28 PM CHAPTER 19 Liaison psychiatry 796 Medically unexplained symptoms 1: introduction A substantial proportion of patients present ing to primary care, or to any individual hospital specialty, will have symptoms for which, after adequate investigation, no cause can be found. Non-speci \201 c symptoms without un derlying organic pathology are very common and usually transient. Where they become prolong ed enough to merit medical attention they may present to any specialty, with presentations such as pain, loss/disturb- ance of function, and altered sensation. Symptom \200\230meani ng \200\231 The \200\230problem \200\231 of medically unexplained symp- toms (MUS) arises, in part, from the different meanings symptoms hold for patient and doctor. Patients presen t to doctors with illness (symptoms and behaviors); doctors diagnose and treat disease (pat hology and other recognized syndromes). The patient wants explanation and treatment for the ir symptoms and the route to this is generally through being given a diagnosis. If there is no recognized diagnosis available the doctor may respond with \200\230there \200\231s not hing wrong \200\231, expecting to be met with pleas- ure. The patient, however, is baf \202 ed \200\224there is \200\230something wrong \200\231 and the symptoms are still there . The doctor may then undertake a number of courses of action: continue to investigate in t he hope of \201 nding something; treat the patient anyway as a therapeutic trial; refer t o another specialty; or dismiss the patient. Psychiatric role The role of psychiatry in the assessment and manage- ment of these patients has changed substantially over recent years (hope- fully for the better). Formerly patients were referred \200\230at the end of the li ne \200\231, often after prolonged, inconclusive tests and unsuccessful interven- tions. Pa tients often misinterpreted (and resented) the referral as suggest- ing that symptoms were \200\230all in your mind \200\231, or were feigned. Psychiatrists sometimes took an overly narrow view of their role and responsibility, unhelpfully dismissing patients as having \200\230no psychotic or depressive ill- ness \200\231, or colluding with the patient \200 \231s desire for a \200\230clean bill of mental health \200\231 in order to return to trea tment-seeking behavior. We are currently at an early stage of our understanding of medicall y unexplained illnesses. While no specialty has all the answers in the management of this p atient group, psychiatry can offer: experience of the presentation of MUS across the hospit al specialties; ability to assess and treat the frequently comorbid depressive/anxiety symp toms; and a tolerance for diagnostic uncertainty and ability to take a long-term view of im provements. Misdiagnosis A frequently expressed concern doctors hold about this group of pa tients is the risk of \200\230getting it wrong \200\231 (often associated with poorly form ed worries about litigation). A long-held belief was that, despite repeated negative \201 ndings, all such patients (or a majority) would eventually be found to suffer from an orga nic disease which would, in retrospect, account for their symptoms. This concern was largel y based on older, poorly conducted studies with signi \201 cant methodological \202 aws. Recent follow-up studies suggest that the misdiagnosis rate for functional illness is 5% (e.g. comparable to other medical and psychiatric diagnoses 19_Semple_Chap19.indd 796 12/7/2012 4:30:28 PM MEDICALLY UNEXPLAINED SYMPTOMS 1: INTRODUCTION 797