Psychiatric history

37-year-old man experiencing a psychotic depression

He has been under the care of mental health services for the past 5 years following an unsuccessful suicide attempt. As a result of which the patient was admitted to an acute psychiatric ward under a section 3 of the Mental Health Act 1983. This allowed a period in which to assess and treat him

He was discharged from the ward after 3/12 and has since been under the care of a CMHT

He is seen regularly by a community psychiatric nurse (CPN) who helps him to take his medication

The patient has regular reviews with a consultant psychiatrist who reviews the medication and monitors his mental health state

He has had ongoing input from a social worker who helped him to get accommodation with a local housing association. The social worker, who is his care co-ordinator, continues to offer support and is responsible for setting up, monitoring and reviewing the overall care package through the Care Programme Approach (CPA)

He is currently reviewed at 6/12 intervals. The CPA meeting is an opportunity for all people involved in the patients care to come together and discuss his progress and ongoing needs (Mental Health Act 1983 Code of Practice (1999))

He has been referred to a mental health physiotherapist by the CPN for back pain

HPC

2-year history of back pain

Has gained approximately 4 stone over the past 3 years since starting an antipsychotic medication

Pain is present in the morning on rising. It reduces as the day progresses but playing snooker once a week seems to increase pain

Investigations

X-ray – taken 2 years ago at the initial onset of back pain. This showed no abnormality

DH

Anti-depressant medication

Anti-psychotic medication

PMH

Mild asthma diagnosed aged 16

Fractured tibia 10 years ago

SH

Lives alone in a one-bedroom flat and has few friends

Once a week he plays snooker at a voluntary sector mental health drop-in centre

Has a very sedentary life and does not engage in any other physical activity

His social worker has also referred him to a befriending scheme and a volunteer visits him once a week

Sleeping pattern is erratic and he reports staying up most nights watching television. He generally sleeps from 4am to midday on his sofa

Diet consists entirely of takeaways

Unable do his own shopping as he gets very anxious in busy environments

Ex-smoker and no longer drinks alcohol

Posture/observation

Overweight gentleman, standing with a forward head position slumped shoulders and flattened lumbar lordosis

Lumbar ROM

Flexion was half normal range as was side flexion bilaterally

Extension was approximately three-quarters normal range

Pain was reported at end of available range flexion and extension

Muscle power

Normal

Neurological examination

NAD

Palpation

Moderate muscle spasm in lumbar area

Antero-posterior mobilisation L3–5 = stiff

Patient’s attitude

Frustrated with being overweight as prior to being unwell he was an average weight

Wants to be more fit and active and to pursue a healthier lifestyle

Doesn’t know where to begin and feels like there are too many problems in his way. For example he could not imagine coming to a gym at the moment as he feels too self-conscious

Appears really motivated to change and willing to take advice and work with therapist to solve problems. He also revealed he had an exercise bike in a cupboard at home

PC

44-year-old man with a 12-month history of low mood, which has not responded well to medication prescribed by the GP

4-year history of leg and back pain following an accident at work

Constant low back pain and leg pain radiating from buttock to posterior upper thigh with no variation in intensity of pain

Patient reports he is unable to stand or sit for prolonged periods; however, he was able to sit for the whole of the interview without moving or adjusting position

Patient’s perception

Feels unable to cope with the pain and the disability as he is in pain when doing ‘everything’

Avoids doing a great deal because of the pain and rarely goes out due to fear of falling or being unable to get home

Believes the reason for his condition worsening is general deterioration

Daily routine

Avoids mornings as this seemed to increase his pain

Gets up late then spends the day in his chair which is placed in a selected position with everything he needs within easy reach

His wife is able to visit her parents in the morning when the patient is in bed but she is unable to leave him the rest of the time due to fear of him falling, despite the patient not falling once within the last 4 years

Mental health

No previous history of mental health problems

The recent condition has been treated by his GP with numerous antidepressants but found no improvement in symptoms, patient is currently not on any medication

SH

Lives with his wife, no children

His wife has given up her job to look after him. She is extremely supportive and admits to having a major role in supporting and assisting 24 hours per day, including all aspects of daily living including driving him to appointments with his solicitor or to hospitals, making all meals and drinks, managing his medication, dealing with solicitor and appointments

He has no social life, no hobbies and spends little time out of the home

He has no contact with his family but does see his mother and father-in-law weekly

The patient worked as a car mechanic for 15 years but has been off sick for the last 4 years

He has a claim against employers for an accident which is being dealt with by his solicitor

Patient is receiving Disability Living Allowance, Incapacity benefit and his wife receives carer’s allowance

PMH

High cholesterol, irritable bowel syndrome

Past psychiatric history – none

Both his wife and mother have a history of back problems

Investigations

X-rays, bloods and MRI all normal

Has been given a diagnosis of mechanical back pain and muscle spasm. He sought a private second opinion but was given the same diagnosis

DH

Tramadol

Paracetamol

Simivastatin

Mental health assessment

Patient casually dressed

Good eye contact and speech normal in flow and content

Gives a comprehensive picture of his symptoms

Concentration was good throughout the assessment

Orientated to time, place and person

There were no thoughts or plans of suicide or self-harm

He describes feeling hopeless about his situation

His sleep is broken and he wakes frequently, managing between 3 and 7 hours per night, which was attributed to pain

Has no enjoyment of meals but no weight loss

States that his mood is low, and he has little motivation

Screening tools

The distress and risk assessment method (DRAM; Main 1992) combines screening tools of the modified somatic perception questionnaire (MSPQ; Main 1983) and the Zung self-rating depression scale (Zung 1965).

Scores:

Zung Score 40, suggesting an element of clinical depression which required treatment with anti-depressant medication.

MSPQ Score 25, suggesting a high level of anxiety and a combined assessment of distress and somatization.

Oswestry Disability Questionnaire (Fairbank et al 1980) Score 80%, which indicates the patient felt 80% disabled by his back pain.

Fear avoidance beliefs questionnaire (FABQ) score 87, which suggests a significantly high level of fear avoidance beliefs and behaviour.

PC

20-year-old woman admitted to a specialist mental health unit for a period of assessment and rehabilitation

Using an electric wheelchair with straps to maintain her back and neck position and a strap to prevent her right arm from becoming too extended

Functional movement in right arm sufficient to drink through a straw and to eat

Presented no movement in her left arm and legs

Extensive investigations failed to identify an organic cause for this level of disability

HPC

Previously had a very healthy lifestyle then developed a rash and fatigue-like symptoms when she was 15 and was admitted to hospital where she had a cardiac arrest

Immediately afterwards she described shakes and tremors that she referred to as making her think of herself as a thunderbird puppet

This progressed to loss of function in first her legs and then her left arm. As her disability increased she was catheterised

Has become totally wheelchair dependent, although her father had secretly obtained video footage of walking 3/12 and 2 years before her present admission

PMH

Fractured right arm falling out of a tree age 11

SH

2 years ago moved into a boarding school for disabled children

Presently awaiting her A level results prior to taking up a university place

Parents divorced when she was 3 years old

Initially she would regularly see her father but they moved away when the patient was 12 following an allegation of rape by her brother’s friend

Prior to her illness there were some difficulties in her relationship with her mother as the patient had become increasingly rebellious

Her premorbid personality was one of a bright teenager, although somewhat rebellious at times, with a keen interest in sport and competing at badminton for her school

DH

Had become involved in illicit drugs in social settings from the age of 13

Since illness began she was on a high dose of painkillers and antidepressants plus a variety of herbal remedies

Patient’s behaviour

Would display long periods of inactivity, then would then take herself out in the wheelchair for hours at any one time

She believed that a miracle cure may occur

Attitude

An angry young lady who resented instruction

Acquisition and use of illicit drugs resulted in episodes of disruptive behaviour

Perceived motivation on admission:

Motivation after input

Admits that it is much harder to do things after her initial illness. After admitting her difficulty she became much more involved with her physiotherapy programme

Progression was stepwise and though directed by the multidisciplinary team was led by patient progression

Outcome

This renewed period of cooperation resulted in the lady leaving the unit able to run and dance, although there was still occasionally a fine tremor when she was tired

PC

23-year-old woman with anorexia nervosa, presents with back pain

She is a patient on a specialist eating disorders unit