Psychiatry attachments

An introduction to psychiatry

The holistic model approach

A 'bio-psycho-social' model is used in understanding cases in psychiatry.

Biological, psychological and social factors all need to be considered when considering a patient's difficulties and also in considering treatment strategies.

Think of cases you see on the wards or in the community using the 'bio-psycho-social' triangle approach, and include these headings in your case formulations.

Team work

In mental health services multi-disciplinary team working is key.

When attending a multi-disciplinary meeting or ward round, arrange a time to talk to other professionals about their roles, for example occupational therapists and social workers.  

Fighting stigma

Mental health has a long history of having been stigmatised.

Even within the medical profession, psychiatry suffers much prejudice. It is important to be sensitive to the stigma of mental illness amongst patients and their families.

It is part of our job to help our patients (and the public) to realise an episode of depression or psychosis is just as valid a reason for poor health as a broken leg or chronic physical illness.

All types of ill health warrant high quality medical care.

1. Mental health examination

While on attachment, learn how to perform a mental state examination: this is the psychiatrist's most useful tool and is the closest equivalent to the physician's objective physical examination.

It purports to offer a clear, objective snapshot view of someone's mental functioning at a given time-point.

2. Diagnostic manual

Familiarise yourself with a diagnostic manual: it is the means by which psychiatrists make diagnoses and looks at clusters of symptoms. The most commonly used clinical manual in the UK is the ICD-10.

A pocket version is available from libraries. ICD-10 is also available online.

3. Reading up

As in medicine, it is useful to read up about a condition after you have seen someone to consolidate learning. A good starting point is the Oxford Handbook of Psychiatry, which can fit into a bag and can be carried around. It is a treasure trove of useful information, and is usefully whipped out in those idle moments when waiting to speak to a patient.

You can also find useful information on the College website and around the web:

Patient information leaflets.

NICE guidelines are available for a large number of psychiatric conditions, from eating disorders to depression.

4. Follow patient journeys

Get to know the day-to-day work of your team, including the consultant and other doctors.

Although psychiatry attachments are often short, it may be a possible to follow a patient through from being acutely unwell to being improved and discharged.

This counters the old adage that psychiatry patients never get better. It would be a nice touch to then do a home visit, post discharge, with the home treatment team!

5. Seeing patients: be proactive but safe

Patients are your best teachers and their stories are what makes psychiatry so fascinating. Do mental health exams as explained above. And check their case notes so you can build up a full picture.

It is also an eye opener to follow core trainees on call: interesting problems tend to present out of hours.

But be safe - make sure you know and follow local guidance. Talk to colleagues about how best to behave and communicate openly with them: raise any concerns you have or areas you are unsure of before meeting patients.

At the start of your attachment sit down with your consultant, and discuss what opportunities and services are available in your area.

It may take some juggling around with colleagues to ensure a balance of experience.

Though it differs depending on where your attachment is taking place, most of the basic services should be available and possibly some specialist services too (eg perinatal).

When you’re talking to people who may be upset or anxious, have a paranoid belief system or are disorientated, it’s easy to see how saying the wrong thing could have a negative impact on them.

The tips below mostly relate to the situation of you, a medical student interviewing a patient on a psychiatry ward.

Dos and don’ts for personal safety in psychiatry

• Do ask someone about the patient you’re going to see before you see them. Have they ever hurt someone before? What happened? Are they disorientated, suspicious or distressed at the moment?
• Don’t feel scared to ask for advice on whether it’s appropriate for you to interview any patient. Ask the ward manager, a senior nurse or an SHO to help you risk assess them.
• Do this in conjunction with reading the notes, incident forms, transfer documents, medical reports etc. Make sure you’re informed!
• Don’t be afraid to take a chaperone with you. It could be your SHO, a nurse or a fellow student, but not a relative of the patient. This is advisable in most cases. Apart from keeping yourself safe, you’ll get feedback on your interviewing skills.
• Do look in a mirror before you interview a patient. If you look smart and professional, you’ll probably find people trust you more easily. Wearing a name badge is always a good idea.
• Don’t wear a long scarf, leave hair loose and flowing, or put anything around your neck that could be used by an angry patient to harm you.
• Do tell someone when you start an interview. Estimate how long you should be so they can look for you if you take longer than that. Ward staff, your SHO, or your team secretary are good choices. And remember to tell them when you’ve finished.
• Do choose an interview room close to main staff areas, and don’t forget to set up the interview room in a safe way before you start. This includes:
  • Making sure the room is clutter free (anything can hurt when it’s flung in your general direction)
  • The “internal inspection window” (the window in the door that allows others to see the occupants) is open.
  • Ensuring the room is well lit so you can be seen through the internal inspection window.
  • Positioning the chairs so both you and the patient have easy access to the door, and so there’s sufficient space between you.
• Do wear a personal alarm. Check the batteries before you start. If these aren’t available, sit near the alarm button in the interview room. If this isn’t available discuss with your team where, how and when you can interview patients safely.
• Don’t forget your manners. It makes it much easier to establish a rapport, get the information you need and have an enjoyable interview. If you see your patient is becoming agitated or upset by a line of questioning, it may be advisable to drop the issue.
• Do end the interview politely, ask for help or leave the room if you don’t feel safe. It’s as simple as that.
  
• Don’t keep it to yourself if there is an incident compromising your safety, however trivial you think it is. It needs to be documented on an incident form if it involves violence and you and the team involved may need to be debriefed. If you’re not sure what needs to happen, talk to your team and ward staff about it and get some advice.

Jude Harrison, a medical student in Dundee, found his fourth year psychiatry placement rather different from what he expected.

“My experience in my fourth year psychiatry placement contradicted the stereotypes of the specialty.

“I was attached to a mental health team caring for patients from a quarter of the general practices in Dundee.

“I thoroughly enjoyed my placement. I have always found mental illness fascinating, but a lot of what I had heard about psychiatry was negative.”

Memorable

“One patient that I saw in clinic particularly stands out in my memory.

“It was a lady who suffered from bipolar affective disorder.

“When she came to clinic she was well; she came across as a calm and pleasant person, very tidy and fashionable.

“I flicked through her notes and read the mental state examination from her last admission to hospital a few months previously.

Contrast

“The contrast between the description of her behaviour then and now was stark: I wouldn’t have thought it could be the same person sat in front of me.

“When she was admitted she had been in a manic phase, chaotically dressed, wildly hyperactive, extremely grandiose and experiencing hallucinations.

“She was very unwell but with treatment she got better - back to ‘normal’.

Patients do get better!

“It was the same on the wards.

“I could see the change in some people even though I was only there for a short period of time – so much for what I’d heard people say about ‘psychiatric patients never getting better’.”

Textbooks

• Psychiatry: an Oxford core text
• Oxford handbook of psychiatry
• Psychiatry at a glance
• Textbook of psychiatry by Puri, Laking and Treasaden
• Crash course in psychiatry

For reference during your attachments

• Pocket guide to ICD-10
• Maudsley prescribing guidelines

Further reading

• Shorter Oxford textbook of psychiatry
• NICE guidelines

Also keep an eye on our publications pages for new books that will be of interest to you.