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bilal

degree and nature

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hello everyone,

new changes to MHA may be coming in the near future which the nature and degree of mental illness will,am sure remain at the core of it for detaining patients.

can anyone elaborate a little bit more on this as it is rather important to understand the meaning and the difference between the two particularly in tribunals!!

cheers

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I've always interpreted nature to include the diagnosis, and the type of presentations& symptoms.

I interpret degree as how the illness affects functioning and interactions with others.

Degree may improve with treatment, the nature tends to be more constant. I tend to focus on nature if I feel that community treatment is not a viable option.

The fact that these are interpretations rather than convictions is prompting me to do a degree in mental health law next year hopefully

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Can anyone elaborate a little bit more on the difference between the two particularly in Tribunals!!

cheers

I remember that in one of the talks by a lawyer a few years ago, he said that we have to mention 'both nature and degree' (although the Law says 'nature OR degree'), in Tribunals. He added that a patient cannot be detained on only one basis (that is; either nature or degree basis). It has to be both.

I later spoke to my Consultant who said that it is fine to say either nature or degree and you don't necessarily have to mention both.

I now think that probably the lawyer was right!

Let's look at these examples. Let us assume that both these patients are refusing admission into hospital.

Mr D, 35 years old,  has Schizophrenia with command hallucinations - 'voices telling me to protect myself from my neighbour with a knife. I carry a knife with me all the time'.

The nature of the illness in this case is such that it increases the risk of harm to others (neighbour).

The degree is the 'severity' of the illness.  

If the illness is not severe (and is mild), he would not be detainable.

In other words, both nature and degree have to be there.

Mrs G, 47 years old, suffers from Severe Depression.  

She has suicidal ideas with intent and plans.

'Nature' of illness in this case places her at a high risk of harm to self.

The degree, which is the 'severity' warrants detention in hospital.  

Are these examples making sense or am I going bonkers?  :-/ :'( :-/

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As far as I understand,

Nature is the pattern of symptoms (and their associated consequences) observed over a period of time or course of the illness eg. relapsing nature of bipolar disorder.

Degree is the severity of symptoms esp those observed at present eg. depression causing severe self neglect.

So I think Nature is more to do with the past history whilst Degree is with present.

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There have been times when 'nature' alone was enough to continue detention.If a patient in a medium secure setting has a history of non-compliance, violence and substance use and appropriate community settings have yet to be identified , the tribunal will not discharge even though the symptoms (ie presentation, and therefore degree)had improved.

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I agree with Evan. Nature alone is sometimes enough for continued detention. Usually tribunals understand the nature of the illness. It is in the manager's hearing, where the managers struggle to understand the nature of the illness, and discharge the patients.

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I agree with Evan. Nature alone is SOMETIMES enough for continued detention. .

Would you agree that, generally speaking, both nature and degree are needed for detention?

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Yes, carefree, generally speaking , i think both nature and degree is required for continued detention. I think it is more ethical

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Thanks for this topic. I have a tribunal today and this has helped clarify the 'nature & degree' issue, to some extent at least. My px has mild LD, schizoaffective disorder, past sexual offending and at present has active hallucinations and delusions, and very recently absconded.

Nature and degree are both implicated here, would you agree?

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Just back from the tribunal. It went reasonably well. The emphasis was on the nature of the LD; in this case assoc. with challenging behaviour and sexual offending, and the degree of the mental illness -florid psychotic symptoms being acted upon...

I know that the more tribunals one attends, the greater one's knowledge of/ experience in them, but does anyone know of any good reading material on this?

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when typing out tribunal reports, we would all know that the 'Blah Blah Blah' includes a sentence that says nature or degree of the illness warrants continuing stay.

the nature of illness is the diagnosis, prognosis and aetiology put together and the degree is severity of the episode with inisght and capacity. or this is my understanding of it.

Nature or degree is fine to detain someone but if you have both,then the lawyers tend to keep quite. I have had a patient whose nature and degree have been severe enough to warrant an extension in the section but the patient was discharged by the panel. we all stood surprised and the worrying thing is the same team has to take care of this patient in the community setting!

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Law definately states Nature OR Degree so you can fulfill either category and be within Mental health Act law. Nature alone used most commonly.

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Not much to add to this ( nature= historical aspects of pts condition, degree=current presentation, only 1 is needed ) except to say that while sectioning someone because of the nature of the illness (eg sectioning someone who has stopped medication who becomes extremely paranoid and dangerous when ill before they actually deteriorate much) can be useful at times it is quite contentious ethically.

Essentially this means that if you have an episode of sufficient severity in the past then you might always be detainable because the nature of your illness in the past can't be changed.  Not much fun !

Be seeing you

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To put it crudely, Degree is symptoms & the distress from these symptoms to the patient and others ' AT THIS POINT OF TIME' akin to point prevalance ! mental state gives the answers to this criterion, usually anyways.

The nature of the illness is non compliance,substance misuse,subversion,,collaboration,Homelessness, loss to follow up & only when all these factors are explicitly linked to violence or self harm does the patient satisfy the criterion of nature of the disorder. Only when this is made by an RMO who knows the patient for long periods or states that he has read all the notes on the patient does the tribunal give weight to your evidence.They may even ask examples of the points you make and you have to be able to give them examples.

Its either or, not both.

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I get this a lot in tribunals:

NATURE: diagnosis, history etc.

DEGREE: How they are now - as in when the tribunal doc saw them yesterday!

You only need 1.

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'nature' is the nature of the patient's condition. It is not history. For eg. . psychois is likely to relapse if treatment is adhered to and the result is increased risk.

'degree' is the degree of the effects due to the patient's condition. for eg... when psychotic...the patient can exhibit unpredictable or aggressive behaviour . It need not be current or happend yesterday

hope this helps

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