Preparation is Key. Preparing for an Initial Psychiatric Consultation. Shannon Girard Lorraine Simpson. March 4, 2013

Transcription

1 Preparation is Key Preparing for an Initial Psychiatric Consultation Shannon Girard Lorraine Simpson March 4, 2013

2 Objective Share the value of data collection and observation documentation, to prepare for an appointment with a Psychiatrist for the first time, using ABC (Antecedent, Behaviour and Consequence), mood and sleep charts The importance of ruling out medical issues prior to the appointment. The desired outcome is to be as prepared as possible to make the best use of the appointment time. The need to gather as much information as possible before hand including, current medications, any previous assessments, any diagnoses that are relevant.. The psychiatric support model for an individual who is congenitally deafblind with a mental illness will be profiled during the presentation.

3 DeafBlind Ontario Services DeafBlind Ontario Services is a provincial organization housing and 24/7 Intervenor services to adults who are congenitally deafblind. Through its supported living arrangements, provision of trained Intervenor Services, and other specialized support services, DeafBlind Ontario Services gives each client the ability to live and thrive more independently. In addition to residential supports, DeafBlind Ontario Services provides specialized community programs. Through respect, trust and teamwork, we are providing leadership in deafblind awareness, programming and services. Inspired by the spirit and determination of the people we support, we are committed to delivering 'senseable' solutions we all can be proud of.

4 Definition of Dual Diagnosis Community Networks of Specialized Care People who have a development disability with mental health issues and/or challenging behavior Ministry of Community and Social Services Persons 18 years of age and older with both a developmental disability and mental health needs It is in the overlap of these two that you have someone with a dual diagnosis Developmental Disability Mental Health Needs Dual Diagnosis

5 Aggression is often deemed as the problem and possibly a mental health issue when it is possible that it is a stress reaction to any number of things Dr. Andrew Wilson, M.D., F.R.C.P.C

6 Our Experience This presentation is based on our own experiences as we have navigated the mental health system on behalf of a number of people we support. We are front line staff, not medical personnel, clinicians, or experts. Each Psychiatrist may want different data, however, there are some general processes that will enable you to make the best use of the limited time you will have. It is critically important to develop a relationship with a behavioural clinical service. In Simcoe we use BMS York Simcoe.

7 Bio psychosocial Model Bio(logical) (physical) Psycho(logical) (cognitive/emotional) Social (external world) Medical, Neurological & Dental Psychiatric Disorders (family history) Medication including side effects Skill Deficits: coping, memory, abstraction, communication, etc. Psychological States: how do they communicate boredom, fear, stress, loss and the unknown and interact with the environment Environment (roommates, transition) Interpersonal (family support, staff change) Programmatic

8 Things the Psychiatrist may want to know! Our experience Is there a family history of psychiatric disorders and what facts and information are you aware of? Have medical procedures been conducted to rule out all physical conditions that may be causing the behaviour? Prepare a list of current medications including prescription/nonprescription, dose, frequency and if there has been any changes in medications in past three months). Better yet, have this list sent to the doctor ahead of time. Provide a chronological history of all past medications and the reasons they were discontinued).

9 Things the Psychiatrist may want to know- Continued Provide any current assessments and/or reports prior to the appointment so the doctor has the opportunity to review. This will allow the best use of the allotted time. What has changed? Why are you here? Why now? What are the behaviour concerns? Have there been changes in the family or living situation? Is this a new behaviour or old behaviours that have returned? What is the intensity and frequency of the target behaviours? What are the patterns you see (ABC Chart)? The doctor may also enquire about changes in activity level, appetite, sleep, sexual activity, bowel and bladder functioning

10 Describe what you see and hear Not the conclusions you have reached based on your own opinions Describe the behaviours you are seeing with many specific examples (charting is key). Instead of saying Fred is anxious lately (that is your conclusion or opinion), say lately while out in public Fred breathing increases, signing is erratic and won t engage with members of the community. Instead of saying I think Fred is depressed (conclusion), say Fred has been spending long periods of time in his room sleeping during the day, which is a new observation. A minimum of 3 months of sleep data (to be graphed by the consultant). Summary of any behavioural data (ABC s and Mood Charts)

11 Sample sleep chart

12 ABC DATA ANTECEDENT = What was going on immediately before the behaviour occurred? BEHAVIOUR = What did you see and hear the acting out person do & how long did it last? CONSEQUENCE = What happened immediately following their behaviour? DATE DURATION WHO ANTECEDENT BEHAVIOUR CONSEQUENCE

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14 Have your Questions Ready Write them down, Be Prepared! Is there a more effective PRN medication (less side effects, quick acting)? Can we move medication times so there is more flexibility for PRN s? How can we engage him more effectively? What can we do if we can t keep him awake during the day? Consider in advance what you want to say and what you hope to get from the appointment. What is outcome you hope to achieve?

15 Case Study 35 year old male, congentially deafblind with a history of self abuse. Family history unknown and no contact. For the last twelve months we have been working with Behaviour Management Services around three target behaviours because the intensity and frequency has increased. He now poses greater risk to himself and others. The target behaviours include: Voluntary vomiting Self Abuse - Punching (face, head, ears) Grabbing staff during activity transitions We have completed ABC charts for target behaviours, tracked sleep patterns for three months and notice that he is sleeping throughout the day when he is not engaged. Staff are attempting to engage every ½ hr with a preferred activity (walk or listening to music). It is during this engagement that he is grabbing at staff. For consistency, there is a small team of staff who work exclusively with this individual.

16 Case Study (continued) Medical issues have not been ruled out completely because it is difficult to assess him (does not allow physical examination). Physicians have been relying on our observations to make a diagnosis. He will not tolerate x-rays, scans and ultrasounds in order to confirm potential medical issues. He needs to be sedated which is difficult to do in the community. What would you do if you were faced with this? What would be the next steps? What resources would you access? How would you present this information to your team?

17 Conclusion Being prepared for the psychiatric appointment will help save time and allow time to advocate appropriately on behalf of the individual. The importance of collecting data prior to the appointment and having all appropriate questions written down and ready to present at the appointment will help to ensure time is spent effectively.