--- module: 045-01 language: en chapter: 45 title: "Mental State Examination, Capacity, Risk, and Common Syndromes" module_title: "Foundations" source_sha256: 39fea89ec338123253bc6971649649fef91980bb87ad913cad3367e8de2f964e --- # Mental state, capacity, risk, and common syndromes ## Orientation and history ### Story, mental state, physical, collateral, course ### Causes include drugs, infection, neurology, endocrine, stress ### Distress does not remove autonomy #### A label does not determine capacity or risk ### Privacy, roles, confidentiality limits, interpreter ### Address instability, intoxication, violence, dependants ### Begin with what happened, why now, what is wanted ### Collateral when cognition, psychosis, or risk limits history #### Receive without disclosing confidential details ## Mental state examination ### Describes the current encounter ### Appearance and behaviour without moral judgement ### Mood is subjective, affect is observed #### Reported and observed emotion can differ ### Thought form: how ideas connect ### Thought content: guilt, delusions, self-harm #### Delusion: fixed false belief outside cultural context ### Visual hallucinations: neurological, substance, delirium causes ### Inattention and fluctuation suggest delirium ### Insight and judgement are not agreement ## Formulation and differential diagnosis ### Predisposing, precipitating, perpetuating, protective #### Across biological, psychological, social domains ### Explains this person, not a list of labels ### Exclude medical and substance causes by phenotype #### Sudden or late onset, fluctuating attention #### Focal neurology, fever, seizures, medication change ### Targeted tests; broad screening yields incidental findings ## Decision-making capacity ### Specific to the decision and time ### Understand, retain, weigh, communicate ### Support: interpreter, aids, pain relief, simple words ### An unwise choice does not prove incapacity ### Delusion matters only if it blocks weighing ### If absent: necessity, directives, substitutes, law #### Least restrictive alternative #### Document evidence, support, reasoning, review ## Suicide and self-harm risk ### Ask directly about thoughts, plans, intent, means #### Asking does not implant the idea ### Not a score or low-medium-high label #### Formulate dynamic and enduring factors, scenarios ### Urgency: discharge, intent, commands, intoxication ### Safety plan is collaborative and specific #### Warning signs, coping, contacts, means restriction #### Not a promise or no-suicide contract ## Violence, vulnerability, and neglect ### Threats, targets, weapons, persecutory beliefs ### Most people with mental illness are not violent #### Substances, past behaviour, access predict more ### Vulnerability: exploitation, abuse, dependants ### De-escalation: calm voice, space, choices, limits ## Depression and mania ### Low mood or loss of interest with change ### Grief does not exclude major depression ### Consider bipolar history, thyroid, anaemia, medicines ### Antidepressants take time and have side effects ### Electroconvulsive therapy for severe depression ### Mania: marked impairment or psychosis #### Hypomania is less severe ### Lithium toxicity from dehydration and interactions ## Anxiety, obsessive-compulsive, and trauma ### Panic mimics arrhythmia, asthma, seizure ### Cognitive behavioural and exposure therapy reduce avoidance ### Long-term benzodiazepines: dependence, falls ### Obsessions intrude, compulsions reduce distress ### Post-traumatic stress: re-experiencing, avoidance ### Trauma-informed care: choice and control #### No detailed retelling at every assessment ## Psychosis and catatonia ### Delusions, hallucinations, disorganisation ### First episode needs longitudinal exclusion ### Antipsychotics: metabolic, QT, movement harms ### Clozapine for resistant illness, needs monitoring ### Catatonia: immobility, mutism, posturing #### Dehydration, thrombosis, malignant deterioration #### Benzodiazepine challenge and electroconvulsive therapy #### Antipsychotics can worsen some cases ## Substance, eating, and personality ### Ask nonjudgmentally about use and goals ### Positive toxicology is not current impairment ### Alcohol and sedative withdrawal: seizure, delirium ### Eating disorders occur at any body size #### Refeeding shifts phosphate and fluid ### Personality diagnosis needs longitudinal context #### Not pejorative shorthand #### Consistent boundaries, avoid splitting teams