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Oh yeah. Ok, cool. Um, so today we'll hopefully be covering depression, anxiety, bipolar disorder, schizophrenia, some personality disorder, amongst other few things. Um, I think these are the, probably the most important topics to cover psychiatry and, um, they're the most important topics to cover joint s as well. I think they're the ones that kind of come up more often than not. Um, and the session will hopefully be recorded and for people to join, er, at any point and we can go through the slides as well. So, uh, next slide if that's ok. So, um, I thought we, we'll start off with a quick question. Uh, I will leave you to read this for about a minute and then have a think about what the, the answer could be. Uh, and then we can walk, walk through it together as if you could start putting your answers in the chat when you, once you're ready. Ok. You can either message the teachers directly or you can, um, you know, message the whole group. Ok. Mm. So there's, uh, you know, just have a, have a read of the think about where you are. Uh, yeah, so, have a think about where you are, where you're based. Um And uh OK, so cool, we've got two answers, we can move on to the answers. So P the QP HQ nine, it is as often used as the main modality of assessment for um depression uh particularly in primary care. Um All the other ones are quite good uh scaling methods. But I think the, the key, the key thing about the question is like I said in GP, um the, the rest of the vignette is more, you know, appealing towards depressive like symptoms. Um which is why ph I is probably the most appropriate answer. Um The PHP nine is actually the one that's also used um by the nice guidance um to kind of categorize the severity of depression, which is quite important in the in the exam. So you may have a question based on P HQ nine results. Um and it will kind of recommend what, what you do next line. So PHP nine of less than 16 is often less severe depression and P HQ uh nine of greater than 16 is uh considered often severe depression. This is a little bit about the screening tools used in, you know, major depressive disorder. Um I've highlighted the fact that some of them are self rated um and some of them are clinician rated as well and that only that just simply means, you know, you can hand the questionnaire over to um the patient and they can, you know, subjectively kind of um assess their symptoms and, and, and feedback that to you, which is quite a, quite useful um as it saves a lot of time, especially if you're in community settings. The uh below you can see is the um the screening questions is often nice recommend to see if someone has depressive illness or elements of depressive illnesses that can, that you can probably uh dig deeper and, and, and try and, you know, delve deeper to what it is that they are experiencing um depression in itself. Uh It's if we can move on to the next part. Thank you. Um So, depression, I mean, there, there, there's a lot of, there's a lot of differences between the CD 11 and the DSM five criteria for depression and how depression is often categorized. Nice, I think in the UK, nice or mainly primary care settings, as I mentioned, use P HQ nine and mainly split into severe and less severe depression. The ICD 10 is the one that's used in the UK uh in Europe as well to look at kind of or categorize psychiatric illnesses as well uh as well as other physical health illnesses. The DSM five is actually a A US based um kind of coding um psychiatric illness uh ca categorization. Um oh uh the uh I mean, the A CD 11 is often splitting depression to different things like single recurrent and dysthymic disorder and mixed depressive and anxiety disorder. There are four main types I've left on the slides um at the bottom in the comments, what the differences are, for example, um recurrent depressive disorders often um once someone gives you a history of at least two depressive episodes uh separated by several months uh without a significant mood um disturbance, for example. So there are slight differences between, between the, between them but the one that you wanna focus on a single depressive, I say so, uh the, the um the SD 10 or 11 sorry uses 10 repress by side which is then classified as often to mild, moderate or severe. Uh both the moderate and severe category of depressive episodes are often um can or can be accompanied by psychotic symptoms. What you see on the screen at the moment is just kind of the brief outline of what it is to have what it is to have depression. Um And some of the symptoms, it's correlated. The key part from here is to appreciate that it's nearly daily um experiences um and for at least uh two weeks, um according to Thursday 11, the main cause symptoms of depression that you wanna look for is low mood and um a a anon as well, which is um not enjoying things that you used to enjoy before the depressive symptoms are often classified into effective neurovegetative uh and cognitive um symptoms. And I suppose if the exam questions ask you what are some of the um effective uh symptoms of depression or which one of these is the effective uh uh since depression, you can kind of think about, you know, the depressed mood, um reduce interest, pleasure and activities. Uh and then neuro or, or cognitive behavior cluster will include things like guilt, low esteem, hopelessness. The these are important for his skis as well, I think. So it's quite a good slide to to have AAA way to guide yourself on navigating depression. So investigations for depression, uh like we mentioned, you often use clinical scales depending if there are clinician or patient l important things to consider when assess depression is thinking about um organic causes. So causes that are not of the disease mind, for example, um things like 24 hour cortisol or um uh vitamin b12 folic acid. These are all things that you can apply to clinical practice actually as well on the right side. Um It is just the nice kind of guidance and criteria as to how they categorize uh severe and more severe depression because ultimately, that will determine if you start treatment as first line or not, we can touch on that too. So the management of often um I wish you uh if we can move on to the next slide, I think it's it's a bit difficult because this, this is a teaching session often I was just speaking at you and rather than kind of engaging you in a conversation about what you think the management will be. But this slide just highlights some of the important things to remember for your exam. Biopsychosocial model is an is kind of format or is AAA an style structure. Um oops on my computer just, yeah. Um and, and so with the biological, a lot of first line is uh exercises or uh selective serotonin reuptake inhibitors which aim to kind of increase your um serotonin in the brain. And that stems from the theory behind why you might be depressed. Although it's quite uh it's a theory and there's multiple different theories as to why you can get depressed. Actually, um just to remember, sertraline is often recommended post for someone who has a myocard infarction at more risk of depression due to chronic chronicity of the of the illness, surgery is recommended. Uh FLUoxetine has the longest half life of all the antidepressants. It is often about 24 to 50 hours now because it's a long half life, it's often it's gonna last in your blood for long longer. Uh Meaning um if you overdose, the effects of FLUoxetine can last a lot longer, and it also means um when, when it comes to discontinuation syndrome. So that's when you suddenly or abruptly stop taking the SSRI if you have something that's quite a long half life is in the blood for a long time. If you suddenly stop taking a Medica, uh you know, an antidepressant at day one, the effects of that medication will last longer and therefore, the symptoms of discontinuation are unlikely to hit straight away. So, uh which is why it links into my next point. Paroxetine is the one that has the shortest half life, meaning it will be, it will quickly reach um half the amount of drug in your body quite quickly. And then ultimately, it, you know, uh the plasma levels falls and as that plasma level falls quite quickly, you get this kind of rebound surge in um serotonin sensitivity in the where you get the symptoms of discontinuation syndrome. And the one I wanted to highlight from the symptoms that you should really kind of uh you should kind of be a telltale thing for you in the exam is uh these things called, described as brain zaps or electric shocks. Um Citalopram is the, we're the only one, the only SSRI that's known to increase lung QT. So if you've got a load of different um antidepressants in like which one increases the lungs of uh increases the um QT syndrome or QT interval in a on an E CG, you're worried about citalopram and a citalopram as well. So those two are the ones associated co that can lead to, to a sadder point. Um And yeah, so, and the second line is uh S SNRI DULoxetine on Venlafaxine. And uh I don't think you need to know too much about those. Uh psychological and social therapies are uh are pivotal in, in treatment. Um But for exam purposes, probably not very important. Um but just be aware, CBT is often use and patients often get referred to it. Um OK, we'll move on to severe depression. It's just a brief touch on what severe depression is often entails. It's mainly people that get hospitalized. Um uh all considered risk itself and others. Um, and, you know, CT is often kind of used in exam settings for very, very severe refractory depressive episode, meaning untreatable, um, uh, catatonia. Um I can briefly tell you what that is. Catatonia is, um, kind of an abnormal state or abnormal motor state. Um, it has a, it manifests, uh, of course, you know, very, very differently. There is a scale called the Bush Francis scale if you're interested, which kind of scales or categorizes, um, the severity of catatonia. And you can have a look at the scale and tell you what to look for basically. Um, uh, but it's, it's not more, very important for your exams if I'm completely honest. So the, the next slide is for you to read in your kind of in your own time. Just take it from nice. It's to do with, uh, kind of SSRI s and interactions with medications. I think these can come up quite often. Um, um, so I'll, I'll just leave you with that to, to have a look in your own time just to be aware that, you know, nsaids, warfarin, Heparin and aspirin, they can all precipitate um gastrointestinal irritation possibly bleed. And so they will more often than not have to be used with uh omeprazole or PPI of some nature. Uh And then we can move on to next question. Uh I'll leave you a moment to have a, a read of that question. Um I suppose I would say think about um yeah, which I wanna give it away. Ok, cool. What else that is? Um ok, sir. Uh uh The, the answer to that question is actually c uh and it's to do with the uh duration of symptoms. So, bipolar disorders often split into mania and hypomania. Um hyp main, the, the main, the key parts are mania. It's greater than seven days. Hypomania is usually less than seven days. Mania is often associated with psychotic symptoms. So just to kind of highlight what psychotic symptoms are when someone says psychotic symptoms, it just means a dis kind of kind of a disorder of um disorder of the mind that causes abnormal interpret interpretation of reality in some nature and that can manifest in yourself with disordered thinking. So to, to kind of summarize what that is, it's either psychotic symptoms often refers to, you know, abnormal beliefs or delusional beliefs. Delusions are kind of false statement or false, held beliefs against societal norms and what otherwise can't be proven to be right. And more often proven to be wrong hallucinations, which is often an abnormal um uh abnormal perception of a nonexisting stimuli more often than not um disordered thinking. So, a AAA problem with your, the processing of your, your thoughts and how you relay those thoughts and how the thoughts kind of connect within each other within your brain. So that could be in the form of tangentiality, circus circum uh so tangentiality or um flight of ideas or as a form of disordered thinking. Um And that's what we're referring to with psychotic symptoms. So those three are the main things to what to, to consider. So for, for you to remember mania greater than seven days hypomania, less than seven days, mania often has psychotic symptoms. And if someone has developed problems with their delusional be, you know, delusional beliefs, hallucinations, they, they will more often than not impair someone's functioning. Ok. Um All right. So if you're, if you've got impaired functional uh capacity, then you, you need some sort of treatment comparatively to hypomania. Um I don't know if anyone, I don't know what the background knowledge is for you guys to know about, you know, bipolar if you know what bipolar disorder is in the first place. Um But bipolar disorder is basically a a mood disorder. Ok? Uh What you can hear, often hear someone say affective mood disorder or affective disorder and it just refers to mood. Um And that means that the main symptoms that you're seeing in someone with bipolar is their mood and that's more often than not very, very um elevated in mania or elevated in hypomania. Um But consequently, um uh the, the, the your mood can also be quite depressed and that will come into your bipolar diagnosis as well. Ok. Um we'll move on. Uh, there, there's a lot of information on the, on the slides you can read in your own time. I just want to kind of briefly go over some of the important things that I think you should remember. Um So we briefly touched on bipolar being a mood disorder. It's often associated with elevated mood, but um often can have also depressed mood. You'll notice that bipolar type two disorder will often have to have so you'll have to have elevated mood but also also have to have depressed mood at some point in in the past bipolar type one, you can be manic. Um and you don't need to kind of have depressed episode in the past. And mania, like we mentioned, is categorized by disor disorder of your thinking disorder of your speech. Um Often people have excessive amounts of spending, um you know, becoming sexually disinhibited, meaning quite promiscuous and risk taking behavior. Um which kind of points towards the diagnosis of bipolar disorder. If you look at the previous slide, you'll see some of the key highlights of what to expect. So management of bipolar disorder um you need to just worry about. Uh uh So we ju you just need to worry or, or remember really that more often than not it's um uh lithium uh that can be used or an antipsychotic of some nature. Um I don't, I don't think you need to necessarily remember all the different antipsychotics used in treatment. Um But I just understand that antipsychotics are often used first line. Um lithium can be used as well if first line, if the patient is going to be on lithium, but they haven't taken it for a long time. So you can reintroduce lithium as well. Ok. But these are quite technical. I think you more be you're more likely gonna be asked about the difference between bi bipolar one, bipolar two and the duration of symptoms. Um But yeah, the, the rest of the information on here is more to do with um like is style answers, you know, community crisis team referral. The thing to note about lithia. Um at the very end says vibrate sodium vapors um can impact fetal development. So it's often not given to women who are not on contraceptives. So that's quite important to consider. So if someone says, all right, there's a lady who's not on contraceptive and they give you a whole load of different um anti epileptic medications which can be used in bipolar disorder, not for the epileptic nature, but uh um help with the mood because they can work in that way as well. Interestingly, va isn't something that you should give. The next slide is um briefly touching on antipsychotics. Um tell us that antipsychotics uh there, there'll be another slide later on um on schizophrenia and why we use antipsychotics. But this is here for you to appreciate the main kind of side effect profile associated with them. And that's uh extra pyramidal side effects like acute dystonia, which is um kind of uh repetitive contraction of some form of muscle, often more often than the nos in the neck or the eyes. Akathisia, which is this inner sensation of restlessness and wanting to move um parkinsonism which you'll see um with Brady can and rigidity and I'll touch briefly on why you get those kind of symptoms later on. But antipsychotics often work on dopamine uh receptors and they often antagonize them. Uh the majority of them do at least uh meaning they block the dopamine receptor and that partially kind of um relays about what causes um psychosis and schizophrenia, which is often elevated levels of dopamine in parts in certain parts of your brain. Ok. So D2 receptor antagonism is the main effect of antipsychotics. With the exception of a few, I don't think you need to remember the all the receptors, but D2 uh is the one that you probably want to remember most. OK. And then we'll move on. Uh This is a collection of uh T tardive dyskinesia, which is it's, it basically, it's a long term side effect of it kind of prolonged use of antipsychotics. Uh But it, it interestingly it doesn't result directly from the D2 receptor blockade, which we talked about earlier on. Um It's, it's essentially people think it's a neuro kind of neuroadaptive change and hypersensitivity to dopamine receptors after long term blockade of those receptors. It's not a direct consequence of DTA. But I suppose the, the main thing to, to remember here, if it is the symptoms that you, you might get on the exam, facial grimacing, lip smacking, mouth bucking. If you see those, you're thinking about tardive um as, as, as the, as the correct answer. So we move on to the next question. Uh I'll leave you a moment to beat. OK? And you, you're welcome to drop answers if you like, we can go through them. Ok. So, uh the, the answer for that is bromocriptine and partially you, you just have to recognize that someone who's on an antipsychotic has a risk of developing uh a neuroleptic um malignant syndrome. Uh so we can move on. Um And neuro exam, you have to kind of ee essentially it's a spot diagnosis more than anything if you see someone who's got muscle rigidity, hypertension, tachycardia. The the the the main thing is muscle rigidity. To be honest with you, cos hypertension, tachycardia, tachypnea. These are also causes of serotonin syndrome and serotonin syndrome is often caused by taking too much serotonin or having too much of the antidepressant or uh different antidepressants like M Aoi or I'm sorry, M Aoi S uh and SSRI S interacting and it kind of creates this picture that's very similar to N MS. But in N MS, you're thinking in more muscle rigidity, increased tone, bromocriptine uh was the answer. Um bromocriptine is a dopamine. Um It's a dopamine agonist and it directly counteracts the dopamine blockade, which is often caused by the um the uh uh antipsychotic which we mentioned more often than not blocks dopamine. Uh OK. Uh We can move on to the next bit. Uh And then this is what I, what, what I mentioned uh Serotonin syndrome often caused by SSRI sm am OA um M OM Ari S or uh they, they often, you know, work together um kind of interact together to produce very similar picture of agitation, confusion, um auto kind of this autonomic hyper drive. Um But here you get uh clonus but muscle rigidity is more and hyperflexible, but muscle rigidity is the one that you are more worried about if uh N MS is the telltale side. OK. You don't have to worry so much about the management for S um Serotonin Syndrome actually. Um but the you turn an antagonist like uh crypto um HEPAT uh is, is, is you, you can see it sometimes in an exam. So, Berri, you think an N MS uh super hepat, you think an um serotonin syndrome. That that's the main thing. OK. Uh The next question, OK. So the, the answer to this is actually um visual hallucinations. Um And, and the, the takeaway um from this is for you to learn what first rank symptoms of schizophrenia are. Now, we, we can move on actually from there. Um So, uh 1st 1st rank symptoms are um the, the there are a collection of symptoms by uh formulated by uh a psycho, a psychiatrist called K Schneider. Um back in the 19, late 19 forties, it's kind of, it's quite helpful to identify schizophrenia. Um and we'll touch base on that in a, in a little bit, but schizophrenia, um the main thing is it's, you know, disturbance er in any of the following modalities, the ones highlighted. Um um uh it's, it's highlighted the, the core symptoms are highlighted in, in, in yellow. Uh and they are often the ones that you kind of have to think about when it comes to schizophrenia. Um So this is free to read essentially as I mentioned before, a thinking disorder. So, delusions, um disorganized, thinking, perceptional perceptual uh abnormality like hallucinations, um cognitive. So the idea behind schizophrenia is there's a collection of different things, there's positive symptoms which add to your experience and there's negative symptoms which take away from your experience and the negative symptoms can be uh volition like loss of motivations or your affect, which is blunted, blunted affect just means. So affect is your the display of the physical display of emotions uh in relation to how you feel. Uh So you can feel very sad but not be able to express things and that may come across as blunted affect. Um The the risk of developing schizophrenia is next. Uh that is uh the next slide. The the thing to take away here is the statistics of monozygotic twins often have a 50% chance of developing schizophrenia. So we move on to the next slide. Um This is just a another kind of reiteration that schizophrenia, you need two of the main symptoms of uh of the main two positive symptoms and they have to be for one month or more. Ok? Um So just remember delusional hallucination, disorganized mechanic or experience of pass passivity. Um and the negative symptoms are also this, this is free to read kind of just to grasp what it is that you're looking for in schizophrenia. You probably won't be asked this in the exam and it's more to do with your kids. Ok. Um The next part is a good question actually. Um I'll give you a, a moment to read. Uh And you, I think you asked the question which said uh uh the patient was hearing voices. Uh The, the question at the time was which of the following is not a first rank symptom of schizophrenia. So you're, you're, you're very right. Auditory hallucinations are often first rank symptoms. So that wouldn't be the answer it's asking for which one is not a first rank symptom. Um And we mentioned first um uh lovely needling. Yes, absolutely. Um So this, so this is, I mean, it's quite, I would say cool information to, to, to be aware of. So if we move on to the next slide, ok. So schizophrenia affects your dopamine in some way, there are four different pathways um in the brain that you need to be kind of briefly aware of and what they kind of influence the positive symptoms of schizophrenia, meaning, you know, like hallucinations, the problems with your thinking, delusional beliefs, they um occur. They, they, they happen because you have too much dopamine in your mesolimbic pathway. Ok. So when you give someone an antipsychotic, they um often treat the mesolimbic path blocker receptors, then your negative symptoms, which are to do with your emotions, your uh motivation um happen because you have a decreased um or a hyperactive state of dopamine levels in the prefrontal cortex. Uh and that's often due to uh which is known as the mesocortical pathway. So I just remember as this your peripheral cortex is often to do with your emotions and your um experience of self and your work and memory. And therefore, if you have decreased levels of dopamine in the area, you, it's gonna affect your kind of personality in a negative way and therefore your affect and your motivation gets slower, mesocortical um cortex, cortices are often to do with different brain regions. And so I just kind of connect the the two cortex, prefrontal cortex, mesocortical. Um And I know that in, in, in the front of your brain is where your personality is. And so decreased levels there, it means um you're more likely to experience the negative symptoms, the tube uh tuberoinfundibular pathway, it's um involved in hyperprolactinemia. And I left an explanation of why that is the case. Um and the extrapyramidal side um side effects occur. Um because of blockade in the nigrostriatal pathway. Nigrostriatal just looks at the basal ganglia and the striatum and that's where your a lot of your movements happens. And if you know about Parkinson's, you know that there is often decreased pathway activity there. And so it gives you kind of uh it gives you Parkinson like movements and that's why we associate um movement disorders uh because of antipsychotics uh with that pathway. So the thing I suppose overall the things to remember, mesolimbic is too much dopamine, which gives you positive symptoms. And that's how antipsychotics works by blocking those uh dopamine receptors in that area. Mesocortical, um low levels of dopamine gives you negative symptoms in that area. Sometimes the theories suggest that antipsychotics because they lower dopamine even more. It can actually make your negative symptoms even worse. Ok. Hyperemia is tuberoinfundibular pathway and the extrapyramidal, which is often to do with your movements like Parkinson's, which is like, you know, bradykinesia rigidity and that sort of thing is in the nigrostriatal striatal kind of rs the striatum. So you kind of you, you know, the striatum is around the basal ganglia and so the blocker there or decrease dopamine there gives you problems with your movement. So this is an important slight to remember those four pathways. So uh going on to the next slide, let's just reiterate, reiterate what um the first rank symptoms are. Um they're not very exclusive to schizophrenia, but um most people with schizophrenia experience those. So visual hallucinations you can see in schizophrenia but or hallucinations are the most telling. Um, sometimes a third person. Um OK. And um, yeah, we'll, we'll move on from here. I'll leave that to you to read out another time. Uh This is just kind of the uh if you click one more time. Uh this is kind of the investigations for schizophrenia. Um or when someone has psychosis of some nature, you're doing a lot of the organic screening. Basically a ct head, um, endocrine screen, it's um it's, it's unlikely that you get examined exactly on, on a, I can't see a question coming up on what investigations you have to do. So if you move on, um OK. Uh this is just to reiterate that antipsychotics are the main stay are the main treatment pathway and they often read or block the do receptors in the mesolimbic area. Ok. All right. So the next question, I'll leave that for you to read. Ok. Um So the, the, I mean, as soon as you see treatment, uh resistance, you're thinking about cloZAPine as the kind of main treatment. All right, treatment, resistance essentially just means someone has tried an antipsychotic. It didn't work, they tried another antipsychotic, it didn't work. So what would we give next? CloZAPine? Um And cloZAPine works really, really well. There's a lot of data and studies uh um suggest that almost 70% of people that didn't respond to a previous antipsychotic will often respond to um cloZAPine C when, when it comes to doing your is um you'll be asked to remember uh things to do with cloZAPine like side effects or engage in a conversation about what it involves. For example, um for the first, for example, 18 weeks, they have to do weekly, full blood count to make sure that they, the neutrophil um level doesn't come down. So if we move on to the next slide, um it just highlights some of the very important side effects and you need to know these for your exams. Actually, most common side effect is constipation or high p elevation. Most life-threatening is Agran uh agranulocytosis, which is uh an increased number of your neutrophils. Uh And if you have neutrophil decrea decreased level, you're unlikely to you, you'll be um your immune system isn't gonna function very well. And so things like sore throats, for example, become quite, um, uh kind of a red, a red flag. Uh because you're more likely to be able to, you're more likely to develop so into another serious illness. So if someone says they have sore throat and they're on cloZAPine, you have to do, uh, a neutrophil count, myocarditis, uh is a, a complication associated with cozine. So if someone said in an exam, it says cloZAPine, someone's on cloZAPine, they have chest pain. What's the most useful investigations you're thinking about doing a troponin, um, to make sure that it's not myo myocarditis. Um, if someone has, you know, constipation, what are you thinking about the most? Um, yeah, hasn't, hasn't opened their bowels or often say someone's on antipsychotic medications, hasn't opened their bowels for a couple of days now, no longer passing wind, which means that someone has now potentially obstructed their intestine completely. It's, uh, cloZAPine is the one that's most likely to give you that. Um, and that's it. I think that's, that's for me. I, I'll hand it over to my colleague. Please ask any questions or any, uh, anything that you want to know about, uh, from the slides. I think psychiatry comes very much, uh, it's not very extensive in progress tests and, and exams, but I think this kind of gives you a flavor for the most important topics to go and you can read the slides in your own time. Um, thanks very much, I'll hand over to. Yeah, thank you. Thank you so much. That was perfect. Thank you. Um Yeah, guys. So any questions put it in the chart and we'll give it to a um either you can ask now or I can give it to him later. So if any questions come up, just put it in the chart. Um Yeah, so I'll ask to carry on. Um Do you mind? I was just gonna say I, I've just made I have a little call to make, do you mind if I uh let you share the slides? Is that OK? I'll be five minutes and I'll be back and then I can share. Yeah, that's fine. I'll just get them up from my side. Have you got the slides with you? Yes, I do. OK. It's fine. Just stop sharing. Mhm. So um he um if you have the feedback just to put that as the, you know, at some point as well. Um just so people can fill that in. Are you happy today or do you want me to? II can just leave the call for later if you want? No, it's OK. Sorry. It's just taking me a few minutes to get it up. Are you sure? Cause I can just kind of, we only have a few minutes. I might as well just I'll just leave it. Um OK, I'll just um if that's OK. Yeah, that's fine. We'll just carry on. Uh which question was it? And it'll be the one before this? Ok. So thank you very much. So we'll just um get onto my side of it if that's OK. So I'll just give you guys a few seconds to read this. Thank you. I just find these questions quite tricky. Um But if you guys could just have a go and that would be really useful. Ok. Very good. Does anybody else have any of the ideas? OK. So if we move on, so I would say the correct answer for this one, it would be a section 52. So a really key aspect to focusing on this question is the actual question was asked which section would be most appropriate within the first instance. So obviously, we've had two different answers. Section two and D which is section 52. So I've just listed here, what are the most common types of sections that are used? So if we just briefly go through them? Um So the sections are categorized into different sections, whether they are for kind of assessment or for treatment and also thinking about what kind of situation um and what kind of clinical setting you're in as well. So just signing off with section two. So that's 28 days for assessment. Section three is six months for treatment. Section four is 72 hours for emergency assessment. Section 52 is 72 hours for assessment of an inpatient. So it's really important to kind of remember that it's for an inpatient. So this would not be for somebody who's went within the outpatient department or somebody in A&E so somebody who's been admitted into a ward, which in this situation, um in this question, the patient had been, they've been admitted um onto a mental health ward. So therefore this would be appropriate. And then we've also got section 54. So that's for six hours for assessment and that's um for a nurse and then common law which is used in the emergency department. So just in terms of differentiating in this kind of case, why a 52 might be used um is essentially you can think of a 52 as buying time for a section two to take place. So a section two is kind of um can be thought of like a formal assessment. Um So a section 52 can be done before a section two is done and it can be done. It's usually done by the patient's consultant, but it can be done by any doctor who's got their full GMC registration. So any two doctor or above, um and this will kind of allow time for um the um the two doctors including the mental health doctors to come to be able to formally do the section 52 assessment. Um So that's kind of the main kind of sections that you need to know for the Mental Health Act. Um And also another really important thing to know is being able to differentiate between the Mental Health Act and the Mental Capacity Act. So for the Mental Health Act allows you to detain a patient who is at risk of harm to themselves or others. And it's for you to treat um their mental illness. So, not necessarily like their physical illness. And that's, that's one that's been caused by their mental illness. So either lacerations or overdose, whereas a mental Capacity Act is more to do with a patients ability to make decisions about their physical health. So their ability to understand where retain and communicate um back um information. Um So it's, it's very important to be able to distinguish, distinguish between both of those two because sometimes people can get um quite confused between both of them if we just move on if that's OK. OK. So we've got another question here. Um So I'll just give you guys a minute to read that. OK. So we've got one answer for five. Is there anybody else has got any? OK. So we'll just move on. Sorry. Could we just go back if that's? OK. OK. So the correct answer for this would be sertraline, which is an SSRI medication as in the um question the patients um exhibiting features of generalized anxiety disorder and we can see this because she's having periods of anxiety and worry about many different aspects of her life. So as the name suggests it's a generalized anxiety disorder. So, um she's get sort of getting anxiety um over many different situations and aspects of her life. So, from thinking about stresses and work and also her family life, and that's what's kind of keeping her awake at light. So, um of course five, which is can be used for sleep irregularities, but in this question, she's more likely experiencing symptoms of generalized anxiety disorder. Um So in which case, that would be for as sri s are first line for generalized anxiety disorder. So if we just move on, if that's OK. OK. So just a bit about the kind of general background of generalized anxiety disorder. So it's categorized by more than six months of excessive worries about everyday issues that are kind of disproportionate, disproportionate to any risk. Um And like I said before, like the name suggests about many different, the anxiety um is to do with many different aspects of their life, so their relationships, their work. Um So it's kind of not kind of limited to one specific situation. Um So if it was kind of limited to one specific situation, like for example, social situations that might lead you more to step um the direction of um sort of like a social phobia or for example, if the anxiety is to do with obsessions and compulsions and that might more lead you down the pathway of thinking about obsessive compulsive disorder. Um So it's usually diagnosed using um clinical features, at least three of which are present most of the time. Um So that just here is like a list. So from restlessness being easy, fatigued, poor concentration, irritability, vessel tension, sleep disturbances. And also if we move on to the next slide, also thinking about like the physical symptoms of anxiety. So, palpitations and chest pain and sort of epigastric discomfort is some of the kind of other symptoms, physical symptoms that can come um alongside um when patients are having generalized anxiety disorder. Um and also the next kind of piece of information that's um on this slide is more sort of applicable to kind of when you guys have to think about doing your I. So it's about having kind of a broader mindset and thinking about organic differentials, which could be um a cause of um the anxiety. So hyperthyroidism. So, in which case, you'd want to perhaps looking at doing some thyroid tests and some cardiac disease, which you would in the first instance, like to do an ECG and and there's also many other conditions. So for example, pheochromocytoma um can also present with anxiety, sweating and headaches as well. So it's really about thinking broadly as well and beyond psychiatric differentials, but also thinking about organic ones as well. Have you gone to the next slide? And just in terms of the risk factors, these can include family history, um physical or emotional stress and also kind of uh kind of co comorbid conditions. So panic disorder and social phobias as well. Ok, if we move on. Ok. So now in terms of the management is, which is what the question um was focusing on. So generally for an anxiety disorder, it's very similar to um kind of depression in that um one of the first line treatments would be cognitive behavioral therapy. Um And then there's also kind of other things that you would like to address kind of holistically looking at the patient's lifestyle. So, sleep hygiene and exercise and also self help. And then in terms of the pharmacological treatments, um so as a thyroid medication would usually be first line, um so you could perhaps use some Cine or citalopram in order to um treat them. Um And then if the first line is ineffective, you can consider giving um a selective serotonin reuptake inhibitor medications, for example, um DULoxetine. Um if the first line is ineffective, so make sure that when you're reading your s pa questions, always, um kind of look at whether they've trialed any medications before. And also, um, the question might ask, you know, or what would um what medication would be most appropriate in the first instance. So it's really about kind of um also kind of reading the question carefully as well because it can kind of trip you up. And then also really important thing to note it. Uh to note is that Benzodiazepines are not routinely used. Um So, and the reason why they're not routinely used is due to um they can be very addictive and also have um withdrawal symptoms as well. So usually if benzodiazepines are prescribed, they're usually prescribed with a very short prescription and a close observation and usually in sort of instances of acute um anxiety as well. OK. So if we move on, so we've got another question here. So this question is quite tricky. But if you guys have a go that would be really good. OK. So d so if we just move on, if that's OK, OK, that's really good. So d is the correct answer um for this, so this question is very tricky, but essentially what you have to do is kind of establish kind of what's kind of going on with this patient, um which is kind of lead leading to kind of a change in their presentation. So in this kind of question, you've got to be looking at kind of the clinical feet, clinical kind of symptoms that they're having and then also kind of bio biochemically at the um investigations that they've had. So for this patient here, if we look at the history, so probably the most important parts to hone in on is that she's kind of, it says initially that she's found slumped by a bus stop. Um And then she has had essentially been admitted into hospital and during the night, a few hours later, you're called to see her. So this kind of kind of kind of leads you to think about that. She, it's likely that she's been admitted. Um, and she may have not had any alcohol during the time of her admission. Um, so during the kind of 6 to 12 hours later, after she's kind of last had, um, alcohol, she's starting to have kind of these withdrawal symptoms. So the symptoms of being very restless, sweaty, um and looking very distracted and hard to take a history from. So these are kind of the kind of symptoms that kind of patients can have um when they have been withdrawing from on cold. Um And then it's also important to look at the kind of investigations that they've given you. So they've given you liver function tests here. Um So a really important one to look at is the GGT. So here we can see that the GGT is around 10 times the upper limit of normal, um which can, which can kind of show you um kind of acute excess alcohol intake and also looking at the raised alt as well. Um So that's a sign of liver injury essentially due to the alcohol intake. Um So you can by essentially put all these kind of clinical features together and they're kind of the biochemical results. This patient is likely withdrawing um from alcohol. Um In which case, um if she's having a very severe withdrawal, you'd like to give um um a benzodiazepine, a long acting benzodiazepine in order to kind of treat this in order to prevent any seizures that could occur. Um just in terms of why the other options are not correct. Briefly, 1 to 1 nursing would be inadequate for this patient because that might be something that you might think of if the patients um only having a very mild withdrawal in terms of IV naloxone, that's something that you'd want to give to a patient who's having an opioid overdose. So usually in the question, you'd see that they'd be having um the kind of try out of an opioid overdose, which would be um sort of a decreased level of consciousness. They'd have pinpoint pupils and also they'd be having respiratory depression um unlikely in the questions with opioid overdoses. They give you um for example, like a VBG which shows a kind of um retaining CO2 as well. Um So that's kind of not what's happening in this question. So that's, it's unlikely that the patients had an opioid overdose. Um I am haloperidol is usually given um can be given to patients who are um agitated as well, but it's not going to be able to prevent um seizure activity um which can come as a result of alcohol withdrawal and for escalations of antibiotic Ceta. So that would kind of be if the patient was becoming um septic um as a result of her cellulitis, um which is kind of less likely in this case, they'd more likely be giving you observations which kind of show that the patient is becoming more systemically and well, in which case, you'd escalate to a broad spectrum antibiotic. So in this question, you kind of have to piece together all the pieces of information to kind of establish that she's withdrawing from alcohol and then um kind of decide on the most appropriate treatment which is oral um benzodiazepine. So if we move on. And so, like I said before, in this question, she's kind of likely to be at the 6 to 12 hour stage. Um and she was having symptoms of tremor, sweating and tachycardia and she's not yet progressed on to the kind of later stage of alcohol withdrawal, which can include having seizures and confusion and delusions. So, really important aspect for the management of um alcohol withdrawal is to use the car scoring. And what this essentially is for is to assess the severity of the alcohol withdrawal because I just for a brief background, you don't have to know it in, you know, very extensive detail, but what the TA R scoring does, it has 10 symptoms of alcohol withdrawal and it basically asks you to rank um each of the symptoms. Um and essentially, if the patient has acr score of more than 10, then you kind of look at um giving them benzodiazepine treatment. Um however, it is they're having, you know, very few symptoms, then you can't just look at um giving them, giving them what we call supportive treatments or giving them fluids and replacement and just close monitoring. Um which was one of the options in the question. However, reduces severity. Um of this um acute alcohol withdrawal case, you would be looking at giving IV um benzodiazepines um and then also giving the patient nutritional support. So, um thiamine is also very important as well to prevent um one of his on opathy as well. OK. So we've got another question. Um Do you mind popping the feedback in the chat? Yes, right. Please guys, please fill in the feedback for, for room speakers. Um You know, and make sure you do that before you go if that's OK. Thank you. Sorry, I just need to get the feed the feedback link. So if you guys just have a think about this question and put your answers in the chart, if that's OK. D has anybody else got any more ideas of what this could be. I'm just getting up the link, it just taking a bit for a while for the leg, but I'll just carry on because we've not got too long left. Um So for this question, the correct answer is actually d um So this question, I also, these questions can also be quite um difficult um because a lot of the times with personality disorders, there can be kind of overlap um in the symptoms as well, but generally, personality disorders can be grouped into three different clusters. So cluster A B and C. Um So in this kind of question, um if we go back to the question, if that's OK, could we go back a slide as well? So in this question, you can see that the patient is essentially having sort of, you can describe it as a kind of negative features of schizophrenia. So he's having the kind of features of social withdrawal, a lack of interest in forming close relationships um as well. So he's having kind of issues um which can kind of mimic the negative symptoms of schizophrenia without the kind of positive features such as the delusions and the hallucinations. So in that way, we we would most likely attribute this to a schizoid personality disorder I put forward. And so like I said, the personality disorders can be grouped into three clusters. Um So in this patient, he's more likely to be fitting into the cluster a type if we just move forward if that's OK. Um So these kind of tables kind of show you the kind of the kind of different clusters and the kind of different common features of each. Um can we just go back to cluster A? So this patient is mo most likely fitting in kind of the schizoid features. Um a key kind of differentiation between schizoid and schizotypal is in schizotypal, they typically have kind of an accusatory nature um towards other people. Um and a kind of um and kind of so like I said, for like a very um persecutory kind of nature to it as well. Um So they can, they can become quite paranoid as well. So if we move forward and then these kind of slides are kind of useful for you to read in your own time. Um But these also give the common features of other personality disorders. OK. So if we move on to the next question, now this will be your final question. So if you have any ideas of what this needs to be, OK. So if we just move on it with this patient, the the um condition that's most likely to be, would be a conversion disorder. Um So in this patient, if we like to, if we could just move forward if that's OK. So with conversion disorder, it typically involves a loss of motor or sensory function um in which, which is what the patient is describing um in this sort of case as well, but they're not consciously, um they're not consciously kind of fabricating the symptoms um in which um patients can do in other kind of disorders as well, um which were kind of in the question as well. So just to talk about some of the other disorders which can lead to unexplained symptoms. Um So these are actually quite commonly asked um in kind of um sp ac questions. So one disorder that you can have is Soma disorder. So, in which the patient has multiple physical symptoms, um and they kind of which they don't typically kind of associate with one specific disorder, but they might have multiple symptoms um such as stomach pain sickness. Um and they refuse to accept reassurance or negative test results. Um Hypochondrial disorder can be similar to, to SOMA disorder. Um in the case that they do refuse to accept reassurance or negative test results. But the key difference is that they group all of their symptoms for one specific disorder. Um for example, they might be very adamant that they have um cancer or they might be very um adamant that they have, for example, Crohn's Disease and whenever they have kind of the specific investigations for these conditions. So for example, um if they were um I believe that they, they believe that they're having these symptoms um have they're not a attributing it to one specific condition, there's also other conditions that were mentioned um in the question. So, um so malingering and autumn Child Disorder as well, so these are also kind of um conditions that you may be examined on. So a very key um um feature of both of these conditions. So, um Munchausen and lingering is that they are essentially fabricating symptoms um or perhaps exam um exaggerating their symptoms um as well. But a very important thing to know is for malingering there is the incentive behind um fabricating the symptoms is likely to be for some personal or material gain. Um So this could be perhaps getting time off work. This could be for um seeking sort of controlled drugs. Um So they are likely to have some sort of personal gain um to bring up. That example could be um for example, seeking benefits from the government. Um However, in Munchhausen's um disorder, and there's no kind of um kind of material gain that they're kind of hoping to get from kind of fabricating their symptoms. Um So that's kind of a very key way to distinguish between them, both if we just, and here's a feedback QR code and we've also pasted it in the chat. So we'd be really grateful um If we could have any sort of feedback um on kind of how the presentation went today. Yeah. Yeah. Thank you guys. Just make sure that you um do the feedback. Thank you for coming and thank you so much. That was um really good, really good teaching there. Um Really good explanations and the same goes for the lump. Um So, yeah, thank you all. Please do the feedback for us. Um Any questions pop in the chart or give us a DM on Facebook slash Instagram. Um And the slides will be uploaded um Hopefully this weekend or early next week with uh hopefully with the recording. Um So, yeah, thank you and good luck for your exams. Um, any issues, just give us a message. Ok. Um, so I'm gonna end this meeting if that's ok with you as well.