Student associate newsletter February 2010

Contents:

1. Editorial
2. Message from the Chair of the Psychiatric Trainees’ Committee
3. Update from the psychiatry societies
4. Report of the first annual meeting of undergraduate psychiatry societies
5. Top tips for the CT1 interviews
6. Freud, our contemporary
7. Increasing Access to Psychological Therapies
8. Psychiatry: brain talk, mind talk
9. Managing psychiatric patients in the general hospital as an FY1
10. Who wants to do a psychiatry attachment?
11. An elective at Broadmoor Hospital
12. Review of the Annual National Forensic Psychiatry SpR Conference 2009
13. Tackling the psychiatric OSCE Station – risk assessment of a patient in the Emergency Department after an unsuccessful suicide attempt
14. Book review:  Don’t Mind Me 
15. Film Review: The Soloist
16. Review: Something is Killing Tate

17. Fancy writing an article for the next Student Associate Newsletter?

 

 

1) Editorial

Vivek Datta, Final Year Medical Student, King’s College London School of Medicine and Student Associate Representative, Psychiatric Trainees’ Committee, RCPsych

 

Psychiatric illness can kill in more ways than one. A tragic reminder of this came on 29 December 2009, when Akmal Shaikh, a man known to have bipolar disorder, was executed in China on drug smuggling charges. It appears that he was acutely manic at the time of the alleged offence. What is not known is whether Mr Shaikh was acutely ill at the time of his execution. We do not know this because he was denied access to a psychiatrist, and denied access to psychiatric assessment and treatment. What we do know is that Akmal Shaikh suffered from an eminently treatable illness which proved to be his death sentence.

 

Whilst the case of Akmal Shaikh is a tragic one, it is also not an isolated occurrence. It is unknown worldwide just how many individuals with psychotic illness are setenced to death. Worse still, there have been a number of instances where law enforcement agents have shot dead acutely manic individuals who have been behaving bizarrely, such as Rigoberto Alpizar, shot dead four years ago at Miami International Airport. It is in situations like these where it becomes clear that understanding mental illness is everyone's business.

 

In this issue, Jon Van Niekerk, Chair of the Psychiatric Trainees’ Committee discusses his plans to support junior doctors interested in becoming psychiatrists, whilst Emma Hogan and Fizzah Ali update us on the activities of some psychiatry societies accross the UK and Jude Harrison briefs us on the first annual meeting of psychiatry societies. For those who are applying for core psychiatry training, Josie Jenkinson shares her advice to succeed at the interview.

 

One unique feature of psychiatry is that it regards a meaningful relationship with another individual as its central therapeutic tool, and this is still the case today. Jeremy Holmes discusses what Freud has to offer psychiatry today, whilst I question whether the government’s Increasing Access to Psychological Therapies programme is really as benevolent as they would have us believe. As research into cognitive and developmental neuroscience advances, a new discourse for conceptualising mental phenomena has arisen. So notes Benjamin Sünkel-Laing, who argues that to privilege a neuroscientific discourse is to sideline the problem of meaning in psychiatry.

 

Psychopathology is highly prevalent in the general hospital, and Hannah Sheftel provides her experience of managing patients in the general hospital. Conversely, Amy Whiteford discusses the benefits of a psychiatric attachment for the non-psychiatrist and Gillian Paterson discusses her experience of forensic psychiatry, whilst Beth Clayton reviews the annual SpR forensic psychiatry conference she attended in November 2009.

 

We wish you a Happy New Year and hope you continue your interest in pursuing a career in psychiatry. And even if you don’t, we hope you agree that understanding mental illness really is everyone's business.

 

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2) Message from the Chair of the Psychiatric Trainees’ Committee

Jon van Niekerk, ST6 General Adult Psychiatry, Greater Manchester West Foundation Trust

 

The last year has been an exciting time to be part of the new Student Associate membership. We are particularly proud of the various student societies set up over the last year. The founding principle of the student societies continues to be that they need to be student-led. I firmly believe that it is imperative to allow students to lead these societies for them to flourish and continue to be successful.The leadership that has been shown by the students continues to be inspirational.  

 

We have recently decided to build on the success of the student representatives and co-opt a foundation year doctor representative onto the Committee. Elections are currently underway and this position will make sure that foundation doctors’ voices are heard. The College is also working hard to highlight the need for expansions of foundation training posts in psychiatry. Psychiatry is the third largest hospital speciality, but only has a 3% share of the overall Foundation Programme posts. We mapped out the foundation competencies in the new foundation curriculum  and work is underway to deliver teaching aids to help those not able to obtain a placement in psychiatry to show evidence of relevant competencies.

 

We have started to put together a great programme for next year’s Student Associate day at the College’s AGM in Edinburgh on 22 June 2010. I would like to thank everyone for their hard work and wish you all a happy 2010. 

 

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3) Update from the psychiatry societies

Emma Hogan, Final Year Medical Student, Brighton and Sussex Medical School

Fizzah Ali, Final Year Medical Student, University of Birmingham

 

It has been one year since the Royal College of Psychiatrists opened their doors to Student Associates, providing young trainees with greater insight into the specialty, whether through provision of extensive e-material or encouraging involvement via the widely promoted psychiatry societies.   

 

Impressive developments have been noted in societies throughout the country. Predictably, societies are at varying stages of development.  The Universities of Nottingham, Manchester, Cambridge and UCL have recently generated societies, whereas Dundee has managed to progress despite encountering difficulties in ascertaining required resources. Kings College London has continued to educate and entertain for yet another year.    

 

Psychiatry societies serve to provide information and support for those interested in pursuing a career in psychiatry, heightening awareness of the nature of psychiatric conditions and additionally dispelling the myths haunting the specialty. The most challenging issue the specialty currently faces is combating stigma - existing not only amongst lay people, but additionally amidst the medically literate at large. Many of the discussions provided by the psychiatry societies aid in eliminating ignorance. 

 

The society at the University of Nottingham, Mind Matters, is working closely with the Trent Division of the Royal College of Psychiatrists. Formed in March 2009 a number of well-received events have already been delivered. A visit from the highly acclaimed novelist, journalist and psychiatrist Dr Max Pemberton exhibited the fascinating career of an individual with one foot in the specialty. Additionally, a psychiatry electives evening revealed useful information for students organising electives. Yet, perhaps most valuable was the launch event ‘DrugSpotting’. Future endeavours include mock psychiatry OSCEs and ‘A Drink with a Shrink’. More information may be accessed on the dedicated Facebook page and website.

 

Formed in May 2009, the psychiatry society at the University of Manchester has also held noteworthy educational events, including a talk on careers in psychiatry and an OSCE workshop. Additionally the medium of debate has been found to be both inspiring and engaging within this Society; “this house believes that depression is a mental illness” has already formed the basis of discussion. Further topics covered include ‘Alzheimers – can you avoid it?’, attended by over 100 students. We hope a similar attendance may be expected for future events including a discussion on the link between cannabis and psychosis. The Cambridge University Psychiatry Society too has had a busy year since their inception in 2009 and have held the speed dating psychiatry careers evening and talks from Professor Lewis Wolpert and Nabina Mitra from the Manic Depressive Fellowship. 

 

Dundee University completed the crucial step-up of affiliating the society to the University Students’ Association, thereby gaining access to wider university facilities and funding for events and activities. Their first event of the academic year was a film night and was followed by a ‘speed dating’ night. UCL encountered various difficulties whilst affiliating their society to the Student Union, but managed to initiate this in November 2009 with a topical discussion on the impact and implication of the fashion industry on eating disorders.

 

The long established society at King’s College London has had another successful year with a variety of events. These have ranged from 'Medicine on the front line: Military Psychiatry' talks by Professor Simon Wessely and Surgeon Commander General Neil Greenburg, encompassing issues of mental illness, trauma management and research within the armed forces, through to the Dr Max Pemberton’s messages on Medicine and the Media and psychiatry as a career option. Future events include talks by Professor Michael Kopelman and Dr James Barrett, a lecture on 'Forgetting and lying: psychiatry and the law' and discussions on 'Homelessness and mental health'.

 

Please do keep us updated with what your psychiatry society is doing.

 

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4) Report of the first annual meeting of undergraduate psychiatry societies

Jude Harrison, Fifth Year Medical Student, University of Dundee, and Student Associate Representative, Psychiatric Trainees’ Committee, RCPsych

 

The first national meeting of the psychiatry societies was held at Guy’s Hospital, London on 9 November 2009. It was kindly sponsored by the Association of University Teachers of Psychiatry and held in tandem with their annual meeting. I attended as a representative of Dundee University Psychiatry Society and as Student Associate Representative on the Psychiatric Trainees Committee at the RCPsych.

 

Delegates were present from Kings College London, St George’s, Cardiff and Swansea, the University of East Anglia, Manchester, Cambridge, Hull York, and even representatives from Glasgow managed to make it down for the session!  The societies at Warwick, Leeds, Oxford, University College London, Peninsula, Sheffield, Liverpool and Edinburgh sent their apologies for the meeting, but most sent their views on the agenda via email. 

 

Challenges

Funding was the first topic up for discussion. Lack of money is a problem for most  students on a personal level, and it is no less of an issue for our societies. Some have had problems with getting official recognition and funding from their Students’ Unions (particularly St Georges and UCL), and others, such as Manchester, find that there are restrictions on how they can spend their money. The medical defence societies, MDU and MPS, are a possible source of income for particular events; some societies have also found money from the local deaneries and their regional division of the RCPsych. Glasgow charges a small optional membership fee. 

 

Some universities don’t seem to like medical specialty societies. One London University was particularly negative when they were approached about a psychiatry interest group; it was suggested that it might even encourage mental illness!  The local trainee representatives at the RCPsych andpPsychiatrists at your local academic faculty will be willing to help run our societies and should be in contact.

 

Different societies advertise events and sessions in different ways.  Many use facebook, whereas some use the university emails and virtual learning pages. There is still a place for old fashioned posters and flyers. 

 

Successes

KCL ran a very successful session ‘The psychiatrist to the olympic cyclist’, which attracted a large number of students including those who are not be interested in psychiatry as a career. Cambridge ran an acclaimed psychiatry career speed dating event which was recently featured in BMJ Careers. At Dundee, our CBT workshop was over-subscribed, and is going to be re-run in the New Year. OSCE practice sessions are also particularly popular; KCL PsychSoc has run such workshops over recent years and Dundee followed suit in March.

 

Next year’s meeting

Manchester Psychiatry Society has agreed to host the next annual meeting. After some discussion, we concluded that there isn’t a time of year that suits everyone and November was thought to be most convenient. It was proposed that, as we did this year, we hold the meeting alongside a conference so as to make it easier to for us to get time off to attend. We hope that students from even more societies will be able to come to the meeting next year and benefit from being involved in undergraduate psychiatry on a national level.

 

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5) Top tips for the CT1 interviews

Dr Josie Jenkinson, CT3, Surrey and Borders Partnership NHS Foundation Trust 

 

So, you’ve decided on psychiatry (and a very good decision it is too), you’ve got through your foundation years intact (just), you’ve navigated your way through the application form and now you just need to get through the interview.

 

The interview process for psychiatry has evolved over the years since MTAS, and, like the other specialties, will follow a multi-station format, which will be standardised across all deaneries with a unified scoring framework. This basically means that there will be three ten minute stations, designed to assess the following three areas: achievement and potential (CV and portfolio), communication skills and empathy, and good clinical care - clinical scenarios to assess safety (foundation curriculum competencies). There will be two interviewers at each station who will have an identical assessment form to complete for each candidate. Candidates will rotate through these stations much like an OSCE, and the scenarios for these stations will be set by the Royal College of Psychiatrists. There will also be a pre-interview task in which you will be given twenty minutes to write a short piece about yourself and your experience in readiness for the station on achievement and potential.

 

With this in mind, you can have a pretty good guess at the type of stations that you might come across. Over the last few years popular topics have been audit, mental capacity, risk assessment post overdose, and management of alcohol withdrawal.

 

These are my top tips for getting through the interview -

 

1. Have all your documents in order. This can take some time to achieve, so get started early. Having a neat folder full of everything you need (passport copy, visa documents, etc – you will get a full list before the interview) goes a long way to making a good first impression.
2. Have a great portfolio. Index it, make it look professional, know where everything is in it, and be able to talk about it. Above all make sure that it has evidence in it of any extra achievements you talk about at the interview.
3. Be prepared. There is a lot to be said for practising answers to certain key questions (why psychiatry, tell me about the audit cycle, etc) but don’t over rehearse or learn answers by rote – it is obvious to the interviewers. However, having clearly not read up at all on key topics is equally obvious and does not look good either.
4. Find out everything you can about the career structure in psychiatry, relevant organisations and speak directly to others who have recently been through the interview process and are currently trainees. See the references below for more information.
5. Know the audit cycle and be able to apply it to an audit that you’ve done. It helps some people to have a crib sheet on things like this to look at during your journey.
6. Smile and relax. If you are well prepared and come across as keen and enthusiastic, you have a very good chance of success.

 

Good luck!

Addendum: the advice in this article is based on current guidance issued by the Royal College. However, this is subject to change, and I would strongly advise that you check the advice on their website on a regular basis in the run up towards the interview.

 

Further useful information can be found at:

www.rcpsych.ac.uk/training/nationalrecruitment/applicationsforpsychiatry.aspx

www.medicalcareers.nhs.uk

www.mmc.nhs.uk

http://careers.bmj.com

 

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6) Freud, our contemporary

Jeremy Holmes, Consultant Psychiatrist, and Professor of Psychological Therapies, University of Exeter

 

Freud is undoubtedly one of the Great thinkers the 20^th Century. But, surely, a bit passé?  What could his brain-child, psychoanalysis, have to offer to a cutting-edge 21^st Century doctor?

 

Well, quite a lot. First, psychoanalysis probes beneath the superficial motives habitually used to account for behaviour. When asked ‘why do you want to become a doctor’, every aspiring medical student has their pat personal-statement answer:  ‘interested in people’, ‘combines science and arts’, etc. But are those the real reasons? Could it be a wish to please one’s mother (‘my son, the doctor, is drowning’!), appease or outdo one’s father, help overcome feelings of low self-esteem, delve deeper into the mysteries of sex?

 

Second, psychoanalysis is holistic. As modern medicine splits into ever-smaller fragments of expertise and technology, psychoanalysis theorises humans as a psychosomatic unity in which genes, upbringing, and life experience impact on body and mind to produce health or sickness. Psychoanalytic Balint Groups, in which practitioners discuss the psychological aspects of their cases in a group format, help doctors use these insights to benefit patients.

 

Third, psychoanalysis, eschewing faux cheerfulness, is realistic about the negatives in human nature. It faces envy, destructiveness, perversity, rivalry, rapaciousness head on – while fostering the mature values of attachment, thoughtfulness, balance and acceptance. All of this is relevant to our work, as patients struggle to cope with trauma, chronic illness, and deprivation. With its emphasis both on empathy and firm boundaries, psychoanalysis can help us cope better with the difficult demands patients make on medical services.

 

Fourth, despite the claims of its detractors, psychoanalysis actually works. For personality disorder (PD), the number needed to treat (NNT) is 6 (c.f. NNT = 120 for aspirin in heart disease). Compared with ‘treatment as usual’,  2-3 years (yes, it takes a long time, but so do diabetic and cancer therapies)  psychoanalytic therapy for PD dramatically reduces numbers of suicide attempts, time spent in hospital, amount of psychotropic drugs taken, and length of time unemployed.

 

Finally, psychoanalysis is beginning to link up with genetics and neuroscience in exciting ways. Childhood neglect or abuse is now known to produce lasting changes in the brain, but these can be mitigated or even reversed through purely social means – an intense intimate relationship with a therapist. 

 

Nobel prize-winner, Eric Kandel, started his psychiatric career as a psychoanalyst, before switching from humans to the slightly simpler brain of the snail.  He continues to advocate psychoanalysis as a treatment and a cornerstone in the science of the mind and its relationships. Are you ready to be the next psychoanalytic laureate?

 

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7) Increasing Access to Psychological Therapies

Vivek Datta, Final Year Medical Student, King’s College London School of Medicine, and Student Associate Representative, Psychiatric Trainees’ Committee, RCPsych

 

In November 2008, the Department of Health announced the beginning of a new dawn in mental healthcare: its Increasing Access to Psychological Therapies (IAPT) programme. IAPT has the benevolent aims of “relieving distress, [and] transforming lives”, by increasing provision of cognitive-behavioural therapies (CBT) for mental disorders. This vision originated from the pronouncements of Lord Layard, who argued we needed 10,000 more CBT therapists to treat depression and anxiety in our communities. One could argue this has been a long time coming. It’s about time the Government adequately funded the Mental Health Services. But why now?

 

In Lord Layard’s proposals (I note he is an economist), his argument was a financial one. Mental illnesses, he pointed out, place a significant burden on the economy through loss of productivity and welfare claims. CBT, he argued, is an effective psychological treatment for depression and anxiety. By treating more depression and anxiety with CBT we would reduce the economic burden of these disorders and the expansion of psychological services would effectively pay for themselves. IAPT then is not for the benefit of the individual, but for society at large. The problem is there is no evidence to support the claims that treatment with CBT facilitates return to work or reduces benefit claims. Indeed the available evidence suggests CBT makes no difference whatsoever to these outcomes. If the primary goal of IAPT is an economic one, then it is also a misguided one.

 

A second point is that although there are a large number of different psychological treatments, IAPT is almost exclusively CBT-based. One can argue CBT is the most empirically supported psychotherapy for depression and anxiety. But at the same time, the cognitive-behavioural model privileges how a person thinks and acts about his situation rather than the situation itself as the cause of the problem. The problem isn’t the recession, or that you’re unemployed, deprived, socially isolated, and affected by widening social inequality – the problem is you. Whilst CBT can be empowering, many people actually have little control over their life situations and good reasons to feel distressed. These attempts to manage subjectivity obfuscate the wider social problems that deserve our attention. Ignoring these problems will only compound them and make IAPT futile.

 

Finally, IAPT is often promoted as a way to reduce prescriptions for much vilified antidepressants. No doubt, antidepressants are sometimes inappropriately prescribed. However, this implies that prescribing medication for mental illness is a bad thing, even harmful, whilst psychological treatments have positive outcomes at best, or are harmless at worst. For the most seriously ill, medications are the most effective treatments we have, and it does no good to stigmatise their prescription. Meanwhile, the optimal conditions for CBT delivery that generated much of the research evidence for its effectiveness are not always matched under IAPT; the adverse effects of CBT and their prevalence in these circumstances are unknown. Whilst we should welcome a genuine attempt to improve access to psychotherapies, the current IAPT programme may ultimately do more harm than good.

 

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8) Psychiatry: brain talk, mind talk

Benjamin Sünkel-Laing, Final Year Medical Student, Liverpool University Medical School

 

The problematic dualism of brain and mind is still very much unresolved. For most medical specialities it is a philosophical issue of little, if any, practical relevance. This is not so for psychiatry, where the paths of neuroscience and philosophy of mind meet head on. Indeed, psychiatry’s stance on the ancient issue of Cartesian dualism has direct implications for how patients are treated.

 

From the metaphysical dualism of brain/mind has arisen a concomitant linguistic dualism: the two discourses of ‘brain talk’ or ‘mind talk’. Brain talk is based on neuroscientific research. Brain talk attempts to convey the neural correlates of mental disorder with the aim of elucidating aetiological mechanisms. However, in doing so, brain talk essentially factors out subjective experience. Psychiatric patients are reduced to behavioural signs of aberrant neurochemistry. This is not to say that the psychiatrist does not relate to the patient on a day-to-day, human level. Yet the psychiatrist often considers the basis of the ‘psychiatric condition,’ a diseased physical object; namely, an area of the brain (and this is apparent to the patient). Whatever valuable offerings biomedical science can make to psychiatry, it lacks the vocabulary to derive meaning from human experience and behaviour. This can be illustrated in the following example: a middle aged lady is admitted with behavioural signs of acute catatonia. Several questions come to mind: What is going on in the brain of this lady? What is the meaning of this lady’s behaviour? What is this lady feeling? Brain talk may one day provide an answer to the first question; that is, the precise cortical neural circuits occurring in the brain which are associated with this psychiatric phenotype. However, answering the first question will give no clues as to the answers to the following two. Mind talk, for lack of a better description, could potentially address the subjective experience of the patient by using a different vocabulary.

 

Neurobiological correlates, whether recorded or not, exist for every experience in life. The most important determinant of psychological health is our context – physical, relational, social and spiritual. Unless these elements are the major focus, psychiatric ‘treatment’ will be limited to symptomatic relief, however appropriate this may be in some situations. The capacity of psychiatrists to help in the healing of psychiatric experiences depends upon their instinctive and cultivated ability to derive meaning from patient’s behaviour and experiences. This, in turn, depends upon the ability to connect to the internal and external context of the patient. On an individual level, this involves understanding the darker side of our human condition. Despair, alienation, and fear are feelings embodied within the psychiatric breakdown. On an interpersonal level, this involves understanding complex group dynamics and dysfunctional communication patterns. Brain talk cannot help in the pursuit of this understanding.

 

Metaphysical duality is an invented concept – it need not exist. Just as our physiology can affect the way we feel, so too our experience can affect our physiology. That is because they arise from the same tapestry. As one enters a potentially threatening situation it is one’s subjective experience that may provoke a myriad of physical sequelae (e.g. palpitations, sweating, blurred vision, etc.). The brain only defines the mind insofar as the mind defines the brain. Despite there being one entity (the mind-brain), our language and attitude reflects a coarse duality. Psychiatry, in its current state, adopts a worrisome bias towards brain talk. All that is gained from interpreting certain behaviour as the sign of brain dysfunction is a distorted understanding of limited therapeutic value.

 

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9) Managing psychiatric patients in the general hospital as an FY1

Hannah Sheftel, FY1, Royal Blackburn Hospital

 

For those of you who are hoping to go on to specialist training in psychiatry you will, like me, have to spend most of your foundation years working in the general hospital and many of you may have very little idea of what to expect with regards to encountering psychiatric patients in these circumstances. Before starting my first FY1 job, I expected to have to wait until my psychiatric attachment in FY2 to experience psychiatry on a regular basis. In reality there is seldom a week in which I do not encounter a patient with significant psychiatric symptoms. Managing these patients appropriately can be challenging. Unfortunately, in a general hospital setting we rarely see psychiatric case notes and, so far, I have yet to encounter a psychiatrist on my ward. The other FY1s that I work with have little interest in psychiatry and, as my seniors have chosen to specialise away from psychiatry, I am often left to see these patients and refer them on by myself. As a result, my learning opportunities in psychiatry have been many and frequent.

 

The majority of patients with psychiatric symptoms have been happy to discuss them with me. Unfortunately, they are not assessed by the psychiatric liaison nurses, our gatekeepers to the psychiatrists, until they are fit for discharge. Patients rarely admit to symptoms that would require compulsory treatment possibly because the patients have been away from the stresses of their lives outside the hospital or because they believe that they will be able to leave the hospital sooner if they claim to be mentally well. One of the hardest things I have found about psychiatry in the general hospital is watching patients, who I know would benefit from psychiatric input, leave without help because that was what they wanted to do. This includes a patient who attempted suicide and reported multiple delusions and agitated behaviour prior to admission but when assessed by the psychiatric nurses denied all symptoms. Worse still was the patient with bipolar disorder who had no current contact with psychiatric services and was taking no medication. Not only had this patient undergone major emotional and physical trauma but he was also expressing both paranoid delusions and delusions of grandeur. He refused any psychiatric input and had to be discharged without ever speaking to a psychiatrist.

 

Despite these frustrations, it can also be immensely rewarding to find that I help one of these patients. The opportunities this provides to learn and improve my skills by working without relying on the help and knowledge of others has by far exceeded my expectations.  I look forward to continuing to experience psychiatry in the general hospital during the remainder of my foundation years with enthusiasm.

 

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10) Who wants to do a psychiatry attachment?

Amy Whiteford, Fifth Year Medical Student, University of Dundee

 

I recently overheard some fourth year students discussing their upcoming psychiatry block. The prevailing attitude seemed to be that the attachment was a ‘waste of time’ for everyone who didn’t plan to be a psychiatrist in the future. This wasn’t the first time that I had heard psychiatry blocks described negatively and it raises the question – are psychiatry blocks only useful for future psychiatrists? 

 

The resounding answer to that is no! Psychiatry attachments provide the opportunity to develop your communication skills, by taking histories from patients who may be unreliable historians or who may have limited insight into their illness, making it difficult for them to describe symptoms. This can be extremely challenging and you may have to utilise other resources, such as information held by the GP or observations made by the family. Spend time talking to patients on your psychiatry attachment and you will gain experience in using different communication techniques and learn the best way to approach and reassure distressed or anxious patients. These techniques can be transferred over to any patient you see, and after the attachment you can use what you’ve learned to take histories even in challenging circumstances, or to pull together information from multiple sources if a patient isn’t clear on their history. Best of all, you’ll know what to do if a patient becomes upset during a consultation and you will no longer need to live in dread of the crying/angry/worried patient!

 

Psychiatry attachments also provide an excellent opportunity to hone your diagnostic skills. Unlike many attachments, you can’t do a barrage of blood tests or other investigations to help you make the diagnosis. All you have to rely on is your own knowledge and the time you spend with the patient. A lot of key signs in psychiatry are picked up through observing the patient during the consultation, for example the depressed teenager with scratches on her wrists that raise the question of self-harm. The attachment can make you adept at noticing these signs, which can be of immense help when seeing patients in other attachments. By then you will be used to observing the patient during consultations and so may notice signs such as pallor or swollen ankles, even if you sometimes forget to examine for these things! You will also be more experienced at taking note of a patient’s body language, and it will be easier to tell if they are still worried or unconvinced by what you have said, so that you can address these issues at the time.

 

My psychiatry attachment helped me to develop a set of skills that I have found immensely useful in all my attachments, and I would really encourage people to get the most out of these blocks. Psychiatry was one of my most useful training experiences, so much so that I’m now trying to get a psychiatry foundation rotation, and I think it should be considered beneficial for all students and doctors, even if they don’t want to be a psychiatrist.

 

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11) An elective at Broadmoor Hospital

Gillian Paterson, Fifth Year Medical Student, University of Dundee

 

Most medical schools allow students to arrange their own modules throughout the course, but when my colleague and I brought up the idea of travelling 400 miles south to spend a month studying forensic psychiatry at Broadmoor Hospital, eyebrows were raised in the deanery. We persevered, and six months later set off for what turned out to be a varied, interesting and enlightening experience. 

 

My interest in forensic psychiatry was piqued when I spent some time in a local prison as part of my general psychiatry block, and my supervisor urged me to spend time in high security. Although I had not organised my own module before, it was remarkably easy to arrange this Special Study Module (SSM). There was a designated student co-ordinator who helped us build a timetable to make sure we made the most of our time. One consultant takes on responsibility for all students, and acts as mentor and supervisor. The mixture of tutorials on subjects such as the Mental Health Act, history of forensic psychiatry and personality disorders, along with ward rounds and patient consultations meant that I learned a great deal. I was encouraged to take part in research, and spent some of my time researching patient’s views about specific medications. Having a specific consultant “looking after” us meant that my colleague and I always had someone to take our questions to; a luxury not always present in clinical attachments! 

 

Taking histories from patients with a variety of mental illnesses was both interesting and challenging, particularly with new admissions who were very psychotic or hostile. I also found that being able to speak to long-term patients about their treatment and hopes for the future gave me a good insight into what life is like for a Broadmoor patient. 

 

Prison visits were another part of the programme, and I was able to travel to Whitemoor prison to observe a patient assessment, and visit Brixton Remand Prison, where I was surprised at how many patients I was encouraged to speak to. Being able to spend time with prison psychiatrists also showed me more of what a career in forensic psychiatry could involve. 

 

The specialty has a large legal aspect, and wrangling with the concepts of fitness to plead or consent to treatment helped me learn how to apply my problem solving skills to areas I had not previously encountered. The concept of “treatability” also came up frequently, particularly in relation to the Dangerous and Severe Personality Disorders (DSPD) unit, where there are often debates over who is suitable for admission, and who should remain in prison. The exposure to patients with DSPD was excellent, and I learned a great deal about assessment and management of patients with PD, particularly antisocial and psychopathic PD.

 

Future plans for the Broadmoor SSM programme include visits to medium and low secure units to give a more balanced experience of forensic psychiatry as a whole. Overall, I would recommend Broadmoor as an SSM to students from any stage of their training.

 

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12) Review of the Annual National Forensic Psychiatry SpR Conference 2009

Beth Clayton, Intercalating Medical Student, Newcastle University

 

This November, Durham hosted the Annual National Forensic Psychiatry SpR Conference. It was a two day event which saw local and international speakers give presentations on the many aspects of forensic psychiatry. For the first time, medical students were invited to attend and were very kindly offered a bursary to cover the costs. I learned about this opportunity through being a member of the ‘Royal College of Psychiatrists on Facebook’, a valuable source of information.

 

All eight students that attended are interested in a career in psychiatry, but we feel that there is a distinct lack of teaching around forensic psychiatry in the curriculum. We wanted to know what forensic psychiatry was all about, and we certainly weren’t disappointed.

 

Both days of the conference were packed with interesting and informative presentations. The first day kicked off with a series of talks about personality disorders, with particular focus on the Dangerous and Severe Personality Disorder Programme. This aims to improve public safety by linking mental health services and prison services to provide new treatments for offenders with personality disorders in the hope of improving mental health outcomes and reducing risk. In the afternoon, the topic turned to the mentally disordered offender’s pathway through the criminal justice system. A poignant presentation was given by Sergeant John Hutchings from the Olympia Police in Washington. He trains fellow officers to assist people with mental disorders who are posing a risk to the public. Through audio and video clips, we were shown how police intervention successfully resolved the threat of a man brandishing a samurai sword on a busy city street. We were also shown the devastating outcome the officers strive to avoid, when one was forced to shoot a mentally disordered man in a fight for his life.

 

The second day started by looking into the future of forensic psychiatry, as laid out by the Bradley Review. This influential report emphasises the need for the early identification and addressing of mental health problems in offenders. The conference drew to a close with pair of fascinating presentations on lying. We learned that most of us are not very good at detecting lies: apparently we are lied to three to five times a day, yet we rarely realise. One possible solution to this is the polygraph test, which is currently undergoing trials on a group of offenders in Britain with the aim of proving that polygraphy could be reliably used in the British criminal justice system.

 

I think all students in attendance would agree that the conference was a very valuable experience. Not only was it educational and inspiring, but it was fun, especially the murder mystery that we were whisked off to puzzle over as we enjoyed a three-course meal!

 

Listen out for the chance to attend this conference next year. If you think you might fancy forensic psychiatry, it will be well worth your while.

 

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13) Tackling the Psychiatric OSCE Station – risk assessment of a patient in the Emergency Department after an unsuccessful suicide attempt

Declan Hyland, Foundation Year 2 Doctor, University Hospital Aintree, Liverpool

 

A common scenario faced by all psychiatric trainee doctors is the risk assessment of a patient who has presented to the Emergency Department after an unsuccessful suicide attempt. This is therefore a common psychiatry OSCE station used in medical student exams. 

 

The examiner will expect you to introduce yourself to the patient and check the patient’s full name. You will be expected to explain to the patient what the interview is about and will be rewarded for putting the patient at ease. 

 

You should begin by determining the seriousness of their suicide attempt. Does the patient have a previous history of self harm? Does the patient have any co-existing mental illness? Have they had any previous involvement with psychiatric services? It is important to establish the patient’s current and previous use of alcohol and of any illicit drugs. The examiner will expect you to identify whether the patient has any support person.

 

Next, you need to assess the patient’s current thinking. Has anything changed since the suicide attempt?  Does the patient have any regrets about attempting to take their own life? You should ascertain what the patient’s current intent is; for instance, if he/she is discharged home following your psychiatric assessment is he/she wishing to attempt suicide again? Suicidal intent is suggested by various factors including whether the attempt planned in advance and whether there were there any final acts, such as the making of a will or leaving a suicide note. You should establish whether the patient took precautions to avoid discovery or rescue, e.g. ensuring they were alone in the house at the time. Ask about what method were used. Violent methods, such as hanging, are more suggestive of lethal intent than alternative means such as an overdose. Ask if the patient sought help after committing the act.  Those who immediately regret what they have just done and seek help from family or friends are probably less at risk than those who do not.

 

The examiner will expect you to be able to identify reasons why the patient will not attempt suicide again e.g. the patient was drunk at the time and not thinking rationally. You need to ask the patient how he/she sees the future. Does the patient feel positive or does he/she have a negative outlook on the future?

 

As with any OSCE station, it is important to reflect back to the patient. To round off the risk assessment, you should invite questions from the patient and thank him/her for agreeing to talk to you. A competent demonstration of your interpersonal skills will always score you marks with the examiner – empathy and establishing a rapport with the patient being two key skills in this clinical scenario.

 

To finish the station, the examiner may ask you to summarise your risk assessment of the patient (low, medium or high) and to suggest a subsequent management plan and,in particular,whether you think the patient should be discharged or admitted for further psychiatric assessment.

 

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14) Book review:  Don’t Mind Me (Judith Haire. Essex: Chipmunka, 2008)

Fizzah Ali, Fifth Year Medical Student, University of Birmingham Medical School 

 

Rating: 7/10

 

Don’t Mind Me is a detailed account of one woman’s passage through childhood neglect, her experience of routinely bearing witness to her tortured mother and her raging father. It details her ensuing tumble into domestic abuse, financial insecurity and sexual infidelity. Most importantly, she describes her experiences in the throes of debilitating waves of psychosis - with the author eventually emerging scathed by side-effects and stigma. The text spawns an interesting discussion of the impact of environmental stressors on the onset and progression of psychotic illness. 

 

The pinnacle of this memoir is her ‘psychotic experience’. The selections of preceding incidents in childhood act as primers, with the later text representing resolution which is tainted with the real possibility of relapse. Haire documents well the insidious approach of her psychosis. She provides us with insight into the early workings of a mind journeying into psychotic breakdown. Loss of appetite and boundless energy, coupled with lack of sleep and inappropriate emotional reactions ranging from heightened fear progressing to paranoia, function as indicators to the clinical student. Haire further offers colourful details of overwhelming auditory and visual hallucinations. The resultant abrupt detriment and immense loss of confidence holds in stark contrast to the initial build up to psychosis, which adds further emotional impact to the account.

 

The latter part of the text illustrates recovery from psychosis and generates interesting clinical pointers for medical trainees and professionals alike. The author’s meticulous attention to the recollection of minor clinical details indicates the crucial role appropriate and empathic professional behaviour plays in patient recovery; ‘The surgeon said ‘well done’ to me...’. Conversely, the consequences of inadequately informing patients – ‘If only I had been warned of the possibility; perhaps I could have made different choices’ may be regarded by some readers as particularly poignant reminders of the extent of influence health professionals hold over a patient’s healthcare options. 

 

Altogether this is a recommended text; certainly as a support manual for patients identifying with issues of abuse and mental illness, and secondly for medical trainees desiring further understanding of psychiatric symptoms, associated life implication, and the role of health professionals. 

 

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15) Film Review: The Soloist (Dir: Joe Wright; USA; 2009; 117 min)

Hannah Short, Foundation Year 1 Doctor, Hinchingbrooke Hospital

 

 

Rating: 8/10

 

In 2005, LA Times columnist Steve Lopez met Nathaniel Anthony Ayers, a homeless musician living on Skid Row. The Soloist is the story of their first encounter, their lives and their friendship.

 

The Soloist is not, perhaps, the film one initially expects. Despite a Los Angeles setting, with Robert Downey Jr. and Jamie Foxx playing the lead roles, there is no typical Hollywood schmaltz. The film is based on real life, and real life does not tie up all the loose ends; nor does it promise that everything will be okay.

 

Robert Downey Jr. is convincing and likeable in his portrayal of journalist Steve Lopez, down on his luck, searching for inspiration in both his work and failing personal life. One winter’s day, Lopez was, in his own words, “scrambling around looking for a newspaper column” when he happened across Pershing Square in Downtown LA and found Ayers playing a two-stringed violin quite beautifully, encapsulated in his own world.

 

Lopez initially delves deeper into Ayers’ extraordinary life in an attempt to breathe new life into his newspaper column, but this leads him into unexpected territory. We discover that Ayers is a talented musician who was once a promising classical bassist at Juilliard before paranoid schizophrenia cruelly robbed him of his aspirations, and he disappeared into the anonymous backwaters of homelessness and LA’s Skid Row.

 

Lopez desperately wants to help Ayers reconnect with his musical roots and he believes Ayers’ tumultuous world can regain some sort of order if this is achieved. He is sent musical instruments by his readers, equally anxious to aid Ayers in his plight, and finds Ayers a safe location in which he can play - Lamp Community (a non-profit organisation aimed at reducing homelessness and improving health) - and a roof over his head. Lopez’s efforts are met with a certain degree of trepidation and suspicion by a perceptibly claustrophobic Ayers, and this leads to frustration and disenchantment on both sides. Lopez feels strongly that Ayers needs medical intervention, but Lamp director, David (played with great compassion by Nelsan Ellis), forces him (and us) to question the role of medication as first line therapy for those suffering from severe mental disorder.

 

The Soloist has been accused of being ‘dull’ by some, and ‘loopy’ by others. What I see is an admirable portrayal of a life shattered by serious mental illness, with Foxx playing the part with disarming vulnerability. This film treats us not only to superb acting, direction and captivating music (including a colourful synaesthetic sequence when Ayers visits the Disney Concert Hall), but also relays an incredibly important message and brings the issues of mental illness and homelessness indelibly to the forefront of our minds.

 

The Soloist is both moving and thought-provoking, and reminds us of the simultaneous fragility and strength of human spirit and friendship. Essentially, it raises more questions than it answers...but then if that isn’t real life, what is?                   

 

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16) Review: Something is Killing Tate (Dir: Leon Lozano; USA; 2008; 79 mins)

Benjamin Cramer, Fourth Year  Medical Student, St George’s University of London

 

Rating: 5/10

 

In Lozano's  film, Tate (Jacko Sims) is hurled into a chaotic and unwanted world of self-destructive action and inaction, whilst the audience is given piecemeal revelation of the 'something' that is killing our eponymous protagonist. Tate is a young, fit, black man, making concerted efforts to isolate himself from the world. In the opening scene he swallows a palmful of prescription pills and resignedly floods his stomach with a bottle of domestic cleaning fluid. The rest of the film is partly a retrospective psychological investigation into the causes of this act, and partly narrates Tate's critical deterioration, persistent rejection of life and eventual germinal recovery. This act is not only a suicide bid, but a symbolic portrayal of Tate's desperate attempt to empower himself (the pills turn out to be Viagra) and purify the intruding memories, the legacy of his stepfather's degrading treatment of Tate (we see a flashback of Tate being force fed food infested with insects).

 

Something is killing Tate is an attempt to raise awareness of, and the aetiological link betwee, domestic violence, mental disorder and suicide, and the repercussions that childhood trauma can have in later life. Lozano's tale encourages viewers to be more sensitive to the symptoms of mental illness in others, to have greater understanding of the social problems that may underlie mental illness and suggests there is a powerfully positive therapeutic role for social support provided by acquaintances in the form of empathy and story sharing.

 

The psychiatric themes raised in the film cover suicide, depression, psychosexual difficulty, childhood sexual abuse, extreme social adversity, substance use, intrusive memories, the value of social support and others still. There is no portrayal in the film of mental health services, and the only input from the medical profession is to mis-prescribe Viagra for Tate's psychogenic impotence. 

 

The characterisation and natural dialogue are strong features of this film, leading to several substantial and believable personalities being presented. The way Tate's depression, flashbacks and aggressive and impulsive behaviour are shown feel realistic, and employ sophisticated but unobtrusive cinematic techniques. 

 

The culminating scenes attempt to be optimistic, showing hope that Tate's difficulties can be overcome, but seem clumsy and saccharine, and lack verisimilitude. Particularly hollow were the ease and speed with which Tate managed to force confession and resolve the domestic horrors inflicted by his stepfather, and the ultra-cooperative and smooth involvement of the police in initiating the process of justice.

 

Overall, the film is a valuable humane study of a young man's struggle with difficulties caused by severe adversity in his childhood, and of its impact on his relationships with lovers, friends and family. The film raises many questions, and would be an excellent film to show at a psychiatry society event to inspire discussion and research into the themes raised.

 

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17) Fancy writing an article for the next Student Associate Newsletter?

If you would like to contribute to the next newsletter, please send your articles, which should be no more than 500 words, to Sacha Evans at sacha01@doctors.org.uk, our new foundation doctor representative, who will be editing the next newsletter.

 

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The RCPsych Student Associate Newsletter Editorial Team February 2010:
Vivek Datta
Fizzah Ali
Samyami Chowdhury
Jude Harrison
Emma Hogan
Jonathan Nicol
Hannah Short

 

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Page last updated on 7 February 2010 by E Baker-Glenn