Thursday 11 September 2008


"Certainty? In this world nothing is certain but death and taxes."
- Benjamin Franklin

Well, he has a point.

This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.

Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."

The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.

Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.

Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."

He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.

Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.

He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."

He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.

The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.

He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.

We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."

We send him on his way.

I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.

As Mr Vonnegut would say, "So it goes."


Catherine said...

Love the Vonnegut reference.

Also love the fact that you are willing to let him make an "unwise choice," even if that means he ends up killing himself. If that is what he chooses to do with his life, so be it. I am glad that your law is written that way.

Sara said...

Hmm...Antisocial personality? Or Narcissistic?

cbtish said...

Double hmm... The point at which you wrote "Crikey" was the point at which I thought "Yes, that's typical of borderline personality disorder" (BPD).

Although some NHS mental health trusts have facilities for treating BPD, others don't, and in those areas there is a dismal tradition of avoiding diagnosis and sending sufferers away to die. The forthcoming NICE guideline may help gradually to eradicate this practice.

Milk and Two Sugars said...

Oh, these fascinating people! An unfortunate waste of time for you and your staff, it seems, but aren't they just dilectable?

From your description I suspect that whilst this bloke might meet the standards of an Axis II disorder, he's more of what I would call here in general practice land, "A right selfish prick." Being a nasty person doesn't have to be pathological, after all, does it, any more than being a nice one?

The Shrink said...

Catherine, indeed, we can't use the Mental Health Act to force treatment upon him and the Mental Capacity Act ties our hands in letting him make unwise choices.

Personality Disorder, a valid thought. Interestingly, this was considered, which is unusual in older adults who've never been given the diagnosis before and it's a diagnosis that can be given out all too readily (which then can be used to justify scant care, as CBTish says). He's been seen by different mental health Trusts. He's had episodes of in-patient assessment and care (albeit not in a unit I've great confidance in). He's had continuity of care thorugh a Consultant (who's okay) and CPN (who's good) over a few years. He's got strong personality traits but none of the previous professionals felt he had a personality disorder.

On assessing him for over 24 hours through this 136 assessment we had no evidence that he had a personality disorder. We specifically looked for this, even though he's a retired gentleman and the odds of developing a personality disorder in later adulthood are modest, but it was clear from his account, his presentation and informant history that he didn't attract a formal F60.x personality disorder.

There was a lack of maturity through him having an external locus of control, seeing many consequences of his actions as someone else's responsibility rather than his own. But we couldn't find that to be a mental illness.

The police/coroner haven't been coming to hassle me yet, today.

Dragonfly said...

I was wondering like sara/msilf was about personality disorders. Sounds like a difficult one (patient/decision/scenario - take your pick).

ditzydoctor said...

sounds like a nasty one. my first thought was personality disorder too!

but then again, there's no law on people just being childish and nasty is there?

Made by Mandy said...

Oh no it's BDP time again!!!

I read your posting with interest as I have someone close to me who has this diagnosis and certainly behaviours which you described this patient as showing.

In my small and jaded view, I think that certain people (be they with BPD or not) are highly manipulative. They use threats of suicide to guilt trip others in to doing what they want. I know this because it is something that I have to deal with (or sometimes I choose not to).

The weird twist on this is that they do take overdoses as well and I don't find out till after the event or when they are in hospital.

And before I give anyone a bad name. The other side to this person is that they are often gentle,kind and compassionate but more changeable than the weather.

The MH services take on this person is that they couldn't give a stuff. I fully appreciate that they are hard work to deal with but is that a justifiable reason for MH services to give up on them?

To me that is like saying "We can only treat or try and treat people who are more pliable"


The Shrink said...

Mandy, he truly honestly doesn't have BPD :)

Anonymous said...

Interesting as always

frontierpsychiatist said...
This comment has been removed by the author.
frontierpsychiatist said...

I'm sure that this is anonymized but it sounds suspiciously like a patient I admitted some time ago. Despite being very elderly when his, slightly younger, girlfriend wouldn't have sex with him, all hell broke loose.

My experience with the sect 136 is somewhat mixed. I often wish that the police would take people to their cells to sober up before I see them. But of course then they couldn't be brought in on a 136....

Kelly said...

When I read that I just saw a selfish git who can't take responsibility etc. I didn't have "personality disorder" jumping out at me.

Shrink, in your experience do some people use that diagnosis/label just to medicalise something when, in truth, such a label is not necessary or warranted?

Made by Mandy said...

Hi again Shrink

I hold my hands up to being overly sensitive when it comes to BPD (and the ensuing minefield that opens up everytime it is mentioned) or I mention it.

I would, however, rather the minefield than brushing it under the carpet because I do feel that BPD is used to diagnose people out of treatment and care.

If, in your opinion, the person didn't have BPD then I trust your judgement. i wasn't there...I am an observer..a distant one at that.

I do feel that there are people that the services would rather not, and don't deal with, because they are difficult and I kinda count myself in there too (at times).


Anonymous said...

Personality Disorder is not a thing that is caught overnight. It's a graduated response to circumstances.
I won't debate the neuropathology cos I don't believe there is one other than that which is formed by experience.
The debate that this guy might be - yet isn't - but could be but his age is not right - would indicate and support that simply - people who can't get joy by reasonable means - resort to unreasonable ones.
He's a PD in the making.
Or not - depending on the way he interprets his options this point forward - and how we respond or not to him.
Please don't ask me what the right choices or responses are to avoid or encourage the development.