Wednesday, 22 July 2009

Is Diogenes Syndrome a Mental Disorder?

Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.

He likes cats, and encourages strays to enter his home through an ever open catflap in his front door, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm, and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.

The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.

Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.

The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker, and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission, and gives a graphic description of what will happen to anyone who tries to make him go to hospital.

This is when the Masked AMHP is brought in. I speak to the psychogeriatrician, who has visited Harry a couple of times, and who clearly is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate, and provides me with a medical recommendation.

I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has basically always been a difficult man, who subjected him to physical abuse as a child and made his mother’s life a misery. He rings him at least once a week, and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to.

I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. We also arrange for the police to be on standby. On the basis of the evidence, I am already leaning towards a decision to detain for assessment.

The house is exactly as described. We enter his living room, where he sends nearly all his time. Cats sidle around the heaps of rubbish.

Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. His answers reveal him to be orientated in time and place. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I talk to him in more detail about the purpose of our visit, he becomes hostile, and asks us to leave.

But I need to discuss the assessment with the GP and social worker. We huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The first legal requirement, that the patient has to be suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital, is not fulfilled. The GP agrees with me. On this basis, I am unable to justify a detention in hospital even for assessment.

By this time, Harry is justifiably annoyed with us, since he realises we are talking about him and he doesn’t like it. He starts to insist that we leave, shouting and repeating this into my face. He does not let me tell him that he would be satisfied with the outcome of my assessment, and bundles us out of his house.

Some sixth sense tells me the social worker is not happy with the outcome of the assessment. On the pavement outside, I discuss the reasons for my decision with him.

Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have life styles others find unacceptable or repugnant. It is often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community as much as possible in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.

Harry could probably be described as having Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself; a study of patients with this syndrome concluded that only half actually had a mental disorder. (Diogenes Syndrome: a clinical study of gross neglect in old age (Clark AN, Mankikar GD, Gray I, Lancet 1975 Feb 15;1(7903):366-8). Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.

Things continue to deteriorate. He persists in making abusive and unreasonable calls to the out of hours service. The carers continue to complain about the rats. By now, they appear to be approaching the size of small hippos. The social worker arranges for a visit with an environmental health officer.

Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.

After lunch, we gather on the pavement outside Harry’s house with the GP. The social worker approaches. He visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as conducting an expedition into the overgrown garden. He could find no evidence of the presence of rats whatever – no rat runs, no droppings, no urine, no evidence of chewing – nothing.

This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to introduce an antipsychotic into his medication in order to see whether or not this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.

I suspect that I have not heard the last of Harry. I will probably be asked to pay him another visit sooner or later. (Unless they ask another AMHP to assess him!) The pressure is likely to continue to mount on me to detain him under Sec.2 for assessment. After all, it would only be for up to 28 days, and only for assessment. At what point should I conclude that there really is no alternative?

Thursday, 16 July 2009

“God told me not to answer the door!”

Jenny has the dubious distinction of being the person I have assessed under the MHA more than any other, a total of 11 assessments over a 7 year period. She is a good example of a “revolving door” patient, ie someone with a severe and enduring mental illness complicated by an unwillingness to engage with services, and a reluctance to take medication, who frequently relapses.

Assessment 1: She was first referred as an emergency by her GP. I assessed her at the CMHT with a community psychiatric nurse. She was 29. She had recently dropped out of a computer studies degree, reporting that the tutor and other students on the course were targeting her and trying to hack into her computer.

She talked freely to us about the problems she was experiencing: "I've been targeted, you see. I'm being stalked via the internet. They are doing it in such a clever way to make me think I'm mad. My computer plays music I haven’t chosen – they’re trying to send messages to me through songs. They’ve included hidden words in the beat of the music.

“And that’s not all – they’ve bugged my house, they’ve put in hidden cameras and they’re broadcasting me on the internet.”

This was possibly the first example I had come across of computer related delusions – once upon a time psychotic people would complain that they were being broadcast on the radio, then that their TV’s were talking to them. Now it was computers.

There was no doubt that she was very unwell, and quite probably we were seeing the first onset of paranoid schizophrenia. Cannabis was also somewhere in the mix. But I didn’t detain her on that occasion, as she was cooperative and agreed to take antipsychotic medication.

Assessment 2: Three weeks later the CMHT Consultant asked me to assess Jenny again. She had attended for an outpatient appointment with him. She was still psychotic, but had insight, and also was still agreeing to take medication. So I again concluded that she did not need to be detained, but continued to monitor her closely in conjunction with the CPN. Gradually, her psychosis subsided.

Assessment 3: A month later the GP again asked for an assessment. Jenny had stopped taking her medication and her symptoms had returned. However, this time there were also religious delusions. She agreed to restart medication, and I again decided to hold fire on a compulsory detention as long as she cooperated with her CPN.

Two weeks later, while I has away on holiday, she was assessed by one of my ASW (at the time) colleagues, since she was not taking her medication, and was detained under Sec.2.

Assessment 4: A month after my previous assessment I got a request for assessment for detention under Sec.3. Although she was taking medication on the hospital ward, she did not think she was mentally ill, would not agree to stay informally, and would not agree to continue with medication. A Sec.3 for treatment was the only option.

Assessment 5: Her CPN asked me to assess her again two years later (she had already had another detention under Sec.3 in the meantime that I had not been involved with). She had stopped her medication and had been smoking a lot of cannabis. She believed that she was in direct communication with God and that her house was being bugged. The Royal Family and security services were also conspiring against her because of her special relationship with Prince Charles. The interview was complicated by her rolling and then smoking a spliff while I was talking to her. She was extremely paranoid and accused me of having special powers (which in a way I did, since I used my special powers to detain her under another Sec.3). Unfortunately, the local hospital had no beds, so she had to be admitted to a private hospital 70 miles away. That was a long day.

Assessment 6: 10 days later, we received a call from this (very expensive) private hospital to say that Jenny had left the ward three days earlier, and should they therefore discharge her from the Sec.3? I will not here repeat what I said to the hospital.

I went to her home and sure enough she was there. She let me in, a spliff in her hand, and I informed her that since she was a detained patient, under Sec.138 of the MHA I had to take her back to a hospital. She took the view that it was a fair cop, and fortunately, the local ward now had beds, so, once she had finished her spliff, she packed a bag and I took her to hospital. (OK, I know this isn’t strictly speaking an MHA assessment, but it is an inherent duty of an ASW/AMHP.)

Assessment 7: 6 months on, it was again being reported that she was not taking her medication, preferring the strongest cannabis she could buy. However, on assessment with the CMHT psychiatrist, she presented as quite well, with good insight, and certainly not detainable on the day.

Assessment 8: But this was not the case 2 weeks later. When, at the request of her care coordinator, I turned up with the psychiatrist and GP at her house we found chaos. Her gas boiler was hanging off the wall and there was smashed crockery littering the floor. I asked Jenny about the damage, and she told me: “The Royal Family and the rest of the inhabitants of Earth are watching me. I know, because they’ve been making my heating click in a special way.”

I asked her whether these experiences might be explained by her mental illness, but she denied this, telling me: “God’s told me I’m not delusional.”

She was detained under Sec.3.

Assessment 9: Nearly a year passed before I again had to pay a visit to her home, again with a psychiatrist and the GP. It was reported she had been smoking a lot of Skunk (always a bad sign for Jenny), and she had hurled abuse through the window when her CPN had tried to visit her. However, on this occasion, she was not going to allow us in. After a discussion on the pavement, we concluded that it was not justified to use a Sec.135 and force entry. She again must have realised that the game was up, because two days later she presented herself at the Accident & Emergency department of the local hospital, and was admitted informally to the psychiatric ward, where she remained for a few weeks.

Assessment 10: A month after her discharge the police were called to her house during the evening, and she was admitted informally to hospital again. After a week or so, she was detained under Sec.5(2) and I was called to assess her for another Sec.3.

Jenny was very upset and tearful in the interview. This was because God “is not very nice”. She told he had first appeared to her when she was 6, and that she was a “chosen person”: chosen “to speak the word of God”. But this was a difficult burden, because “God thinks more of football and singing than protecting. I hate communicating with him when he’s not acting normal”. Then she broke down, sobbing, “I don’t know if I can live like this because God won’t leave me alone”.

Following this admission, she was taken on by the local Assertive Outreach Team, who work with patients who frequently relapse or are difficult to engage. In the next three years, there was only one further admission to hospital.

Assessment 11: A call from the Assertive Outreach Team consultant. Jenny was smoking skunk again, messing about with her medication, carers expressing concern, etc.

She did let us in this time. Initially she presented to us as quite together, although told us that she didn’t need mental health any more. It was suggested that it might be an idea for her to come into hospital, but she was against this: “I need to be with God having my hair done tomorrow.”

She admitted that God was speaking to her again. We suggested that she was again mentally unwell and needed to go into hospital, and we were going to admit her under Sec.3. She was unhappy about this.

“You know,” she said, “God told me not to answer the door. It’s really going to piss Him off if I don’t have my fucking hair done tomorrow!” She stormed out of the room.

Just as I was wondering whether we were going to need the police, she came back with a packed bag.

“Let’s go,” she said. Perhaps she was beginning to learn something.

To date she has not had a further admission. Perhaps God has finally left her alone.

Saturday, 11 July 2009

My First Mental Health Act Assessment (Part III)

On 28th September 1983 the 1959 Mental Health Act was rescinded. I ceased being a Mental Welfare Officer and on that day became an Approved Social Worker. It certainly sounded more modern, as did the 1983 Mental Health Act itself, which incorporated more human rights safeguards in the process of compulsory detention in hospital.

As well as having a few more assessments under the 1959 Act under my belt, those to be designated as ASW’s had actually had some training in the new Act, so this time I felt a little more prepared when I received my first request for an MHA assessment under the 1983 Act two weeks later.

I was on call, and the request came in the early evening. Her name was Emma. She was in her 30’s, married with two young children, with a diagnosis of bipolar affective disorder. She had been seen by her GP earlier in the day, but had removed herself from his presence when it looked as if he might be considering admitting her to hospital. She was now in a police station about 25 miles away from the town where I worked, detained under Sec.136, having been removed to a place of safety from a public place by a police officer who had reason to believe she may have been mentally disordered. She therefore had to be assessed by an ASW and a medical practitioner.

(All the sections in the 1959 Act changed in the new 1983 Act – Sec.25 became Sec.2, Sec.26 became Sec.3, Sec.29 became Sec.4 – with the exception of Sec.136, the only Section the police could impose, which remained the same. We ASW’s assumed it was because the police would never be able to remember a new number, but perhaps we were too cynical.)

Before I went out to see her, I took the precaution of visiting the GP, who was still in surgery, and got more information. She had been going high for a few weeks, and had managed to obtain a bank loan, purchase a franchise with an international cosmetics chain, and had opened an office in the town, despite having no experience in this field whatever.

I obtained from him two medical recommendations – one for Sec.2, and another for Sec.4 – just in case – and then set off for the police station.

When I interviewed her, Emma seemed quite calm. She was clearly extremely tired, having not slept for several days, but sensibly recognised that it would be a good idea to go home, take some medication, and get some sleep.

I decided that, having assessed her, she did not need detaining, and could therefore be discharged from the Sec.136. The police sergeant thought otherwise. He had read Sec.136 of the Act, which stated that the purpose of detention under Sec.136 was for the person “to be examined by a registered medical practitioner and to be interviewed by an approved social worker”. Since she had not been examined at the police station by a medical practitioner, he could not allow her to leave the police station. He was probably right. However, my interpretation of the Act at that time was that since she had been assessed by a medical practitioner that day, she did not need assessing again by another medical practitioner in order to fulfil the requirements of Sec.136.

After a considerable and sometimes heated discussion, he acceded to my superior knowledge and allowed me to take her back to her home town, with a female special constable as an escort.

What an interesting journey that was. Once we had set off, Emma started to go high again. I realised that she was rapid cycling. As we drove, she became more and more charismatic, and even appeared to physically increase in stature. It was an awe-inspiring sight. A messianic glow seemed to emanate from her being as she told us about her plans for world domination through the cosmetics industry. I was becoming steadily more alarmed the more I drove – would the car be big enough for the three of us, or would she continue to inflate indefinitely until the car burst asunder? The female special constable however, with very little experience of mental illness, was drawn completely under Emma’s spell. Not only did she take issue with my opinion that Emma was mentally unwell, but she was even considering investing her life savings in Emma’s scheme.

At last we arrived at her home. By then I had serious misgivings about leaving her with her husband and children in this state, and when her husband saw her, I could tell he was even less happy than I was. She had no intention of taking her medication and going to bed; she was instead going to her new office to order even more of the cosmetics, right then, and then she was going to see her solicitor to get a divorce.

I knew that chaos would ensue if I were to leave her, and in those days without mobile phones I suddenly felt extremely tired and lonely and isolated. Why on earth did I ever decide I wanted to be an ASW?

In an attempt to regain control of the situation I calmly but firmly indicated to her that this was not a wise thing to do, that she was extremely unwell, and that she really had no option but to go to hospital. Somewhat to my surprise, she agreed that I could indeed take her to hospital, so before she could change her mind I marched her to the car, again accompanied by the female special constable, who by now realised that something was severely amiss with Emma and was now reluctant to sit next to her, or even be in the same vehicle, and drove the 15 miles to the hospital, knowing that if I could get her safely ensconced on the ward, then if necessary we could keep her there on a Sec.5(2).

By 11.00 pm we arrived at the hospital, and we walked down the long, dim, silent corridors until we at least reached the ward. I sat her down in the nursing office with the admitting nurse, beginning to allow myself to feel relief. This was when she drew her trump card.

“I’m not staying,” she said.

“But you agreed that you would go to hospital.”

“I agreed that I would go to hospital. I didn’t agree that I would be admitted!” She gazed at me in triumph. She had outwitted me.

But I had my own trump card. I left the room for a few minutes, filled in a form, and returned.

“Emma,” I said to her, “you are now detained under Sec.4 of the Mental Health Act 1983. That means that you have been admitted for assessment for up to 72 hours. There is no right of appeal against that decision.”

The Consultant converted this to a Sec.2 the following day, which of course did provide her with the right to appeal. So two weeks later I had my first Mental Health Review Tribunal of the 1983 Act. But that’s another story.