--- module: 045-02 language: en chapter: 45 title: "Mental State Examination, Capacity, Risk, and Common Syndromes" module_title: "Phenomenology, dynamic risk, capacity, and psychiatric medical safety" source_sha256: 4682a1b6c75d67e96a9c17dc8ea720eb30df888df1426af19c7cd6ed8ec726d9 --- # Phenomenology, risk, capacity, and medical safety ## Phenomenology and observation ### Describe experiences before naming a syndrome ### "Hearing a voice" has many origins #### Hallucination, intrusive thought, dissociation, delirium #### Clarify location, quality, control, commands ### The interview is itself an examination #### Movements are observations, not interpretations ### Affect: range, intensity, stability, congruence #### Flatness: negative symptoms, depression, parkinsonism ## Thought form and content ### Circumstantial reaches the point; tangential does not ### Flight of ideas: rapid understandable links #### Loosening makes links hard to follow ### Explore evidence and conviction without arguing ### Obsession recognised as one's own thought ### Delusion: conviction despite counterevidence #### Overvalued ideas lie between ### Insight is dimensional ## Cognition and delirium ### Screen if acute, atypical, late, or fluctuating ### Arousal and attention before memory #### Months backward and digit span catch inattention ### Psychosis and delirium can coexist ### Visual hallucinations, abnormal vitals suggest medical cause ## Decision-making capacity ### Functional, not a global cognitive label #### Food yes, complex discharge perhaps not ### Understand, retain, weigh against values, choose ### Reasoning process, not agreement, decides #### Rational refusal of surgery is possible ### Delusion counts only if it blocks the decision ### Record own-words understanding and weighing #### Diagnosis or test score is not a conclusion ### Fluctuating: decide at the best time of day ### Substitute judges by the person's values ## Suicide risk and discharge ### Formulate foreseeable pathways, not a score ### High lethality, concealment, escalating intent ### Test protective factors for reliability ### "Low risk" implies false certainty ### No-suicide promise does not prevent action ### Discharge: housing, time alone, access to means #### Family presence is not proven support #### Post-discharge period stays changeable ### Handover: what changed, what to do ## Violence and emergency intervention ### Dynamic and contextual, beyond diagnosis ### Most are not violent, more often victims ### De-escalate: distance, one calm speaker, choices ### Restraint and medication as last resort #### Check allergy, pregnancy, QT before drugs #### Monitor airway, oxygenation, rhythm after #### Prevent positional asphyxia, rhabdomyolysis ## Depressive and manic syndromes ### Major depression can coexist with bereavement ### Bipolar depression: monotherapy may destabilise ### Thyroid, sleep apnoea, steroids can mimic ### ECT for psychotic, catatonic, life-threatening illness ### Reduced need for sleep: the person feels rested ### Impairment, psychosis, admission mean mania ### Manage financial, sexual, driving consequences ## Psychosis and catatonia ### Psychosis is a syndrome, not schizophrenia ### Negative symptoms overlap depression, sedation ### Organic red flags in first episode #### Fever, seizures, autonomic instability, postpartum #### Tests chosen by phenotype, not a panel ### Baseline weight, glucose, lipids before treatment #### Separates drug harm from disease change ### Catatonia: stupor, mutism, waxy flexibility #### Aspiration, thrombosis, contracture, hyperthermia #### ECT highly effective; antipsychotics may worsen ## Eating disorders and refeeding ### Unstable at any body size ### Insulin drives phosphate, potassium, magnesium into cells #### Sodium and water retained #### Thiamine deficiency and cardiac failure ### Risk from rate of loss, not current size ### Replace thiamine and electrolytes first ### Excessive caution prolongs undernutrition ## Substances and the final plan ### Specific, nonjudgmental substance history ### Opioid overdose is ventilatory failure ### Toxicology shows exposure, not impairment ### Separate medical crisis, syndrome, capacity, risk ### Beyond medication: sleep, housing, finances ### Record reassessment time and responsible person #### Uncertainty must not blur the safety plan