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PSYCHIATRY FINALEAZY BY LOIS BOWNEvent Topics Substance Use disorders Eating disorders Neurodevelopmental disorders Psychosis related disorders Mood disorders Anxiety disorders Personality disorders Disclaimer This session discusses various mental health conditions including: • Substance use disorders • Eating disorders • Neurodevelopmental disorders • Psychosis • Mood, anxiety and personality disorders. Each person will have their own experience of mental health which may not be represented in this session, and with the rise in mental health disorders, we recognise that some of this information may be triggering. If you feel uncomfortable at any point, please feel free to leave the session or send us a message telling us how we could improve. This session’s content is based on UK guidelines, local guidelines may vary.Approach to psychiatric conditions https://www.medicinejournal.co.uk/article/S1357-3039(24)00134-8/fulltext Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Organic disorders Eating disorders Substance Use Disorders Neurodevelopmental disorders Binge Eating disorder Alcohol ADHD Bulimia Nervosa Drug Autism Anorexia Nervosa Binge Eating disorder What Signs/symptoms A condition characterised by the • Feeling you are not able to stop eating consumption of large quantities of food once you start associated with a loss of control and no • Associated with marked distress follow up compensatory behaviours. Diagnosis Treatment • Recurrent episodes of binge eating, 1. Guided self-help programmes at least once per week for 3 months. 2. Group eating-disorder-focused CBT • DDx:overeating, bulimia. (CBT-ED) Bulimia Nervosa Signs/symptoms What • Inappropriate compensatory behaviours include Characterised by binge eating episodes followed by compensatory behaviours. vomiting, misuse of laxatives, strenuous exercise, and insulin omission. • Preoccupation with weight or shape strongly influences self-evaluation Diagnosis Treatment • Recurrent episodes of binge eating with compensatory behaviours at least once per 1. Guided self-help programmes week for 3 months. 2. Individual eating-disorder-focused • DDx: Binge eating disorder, personality CBT (CBT-ED) disorder. https://www.cambridge.org/core/books/abs/medical-management-of-eating-disorders/plate-section-pdf-only/EFCBC8E604AC2509D0D1F3844407E860parotid hypertrophy https://pocketdentistry.com/esthetic-dentistry-and-eating-disorders/ - Russell'ssign Anorexia Nervosa What Signs/symptoms A disorder characterised by extreme • Excessive preoccupation with body weight or shape restriction in energy intake resulting in • The pattern of behaviour aimed atmaintaining an significantly low body weight orfast abnormally low weight • Physical: amenorrhea, bradycardia and hypotension. weight loss. Diagnosis Treatment • BMI < 18.5 or >20% weight loss in 6 Individualised CBT-ED, MANTRA and months. SSCM and FT-AN. • DDx: Bulimia, EDNOS. Emergency admission.EMERGENCY ADMISSION Risk of refeeding Severely compromised physical health Severe risk to self Question 1 Section her under the MHA A Daisy has noticed other peopletalking behind her back, and a few people havetold her that shehas lost B Section her under the MCA a lot of weight. She “feels so fat” and thinks she might have even gained weight as she struggles to get up Voluntary emergencyadmission to thehospital C from sitting now and feels her heart racing. D Refer her to the CMHT What should you do first? E Refer for CBT-ED Question 1 Section her under the MHA A Daisy has noticed other peopletalking behind her back, and a few people havetold her that shehas lost B Section her under the MCA a lot of weight. She “feels so fat” and thinks she might have even gained weight as she struggles to get up Voluntary emergencyadmission to thehospital C from sitting now and feels her heart racing. D Refer her to the CMHT What should you do first? E Refer for CBT-ED Lack of Insight but Preserved Lack of capacity Capacity- USE MHA - USE MCA 1. "I understand my organs might fail if I don’t gain 1. ”So, the only reason you’re refeeding me is to make me gain weight.” weight.” 2. "I remember you telling me about my potassium 2. "I don’t remember any risks.” levels being dangerously low last week” 3. "It doesn’t matter if my heart stops because I don’t want to gain weight. 3. "I know there’s a risk to my heart, but I would rather die than gain weight.” Gaining weight is the worst thing that 4. "I don’t want refeeding even if it puts my life at can happen.” 4. "I don’t know." risk." Medications to Substance Withdrawal Substance Use disor eruce Treating overdose Other facts Dependence What Begins around 6-12 hours IV Thiamine (preventtoms Delirium tremens (onset and peaks at 48-72hr. Disulfiram, Wernicke-Korsakoff) and 48-72hr after a drink)- AlcohA condition characterised by theand naltrexone and lo•g-CRAVINGS → TOLERANCE → WITHDRAWALions, confusion insomnia, hallucinations, acamprosate. benzodiazepines and autonomic seizures, sweating, tremors (chlordiazepoxid ), CIWA- hyperactivity. recurrent useand tachycardia.uch as Ar scoring. Most misused. • Inability to stop despite significant harm alcohol,opioids and stimulants causing • Prioritising the substance abov elsel withdrawal, Opioids (e.g., Begins around 6-12 hours hallucinations are rare significant iand peaks at 48-72hr.ress. Buprenorphine • Preoccupation with the substance heroin, Muscle aches, yawning, and naltrexone. Naloxone and opioid withdrawal is morphine) runny nose and diarrhoea. not often fatal. Diagnosis High risk for overdose. Treatment No antidote. Treatment Begins around 6-12 hours • Motivational interviewingpression, anhedonia • The presencand peaks at 48-72hr.toms for depends on symptom and sleep disturbances in Stimulants (e.g., Psychomotor retardation, CBT and pr•fiRelapse prevention mediwithdrawal, unlike alcohol cocaine,12 months fatigue, sleep disturbances rehabilitation fo• sSupporting complicationand opioids.ndition, i.e., gradual nutrition to methamphetami including vivid dreams and programmes. activreduce the risk of refeRisk for cardiovascularmine supplementation ne) • MILD: 2-3, MODERATE: 4-5, SEVERE: 6+ verapamil for chest pain increased appetite. Really and antipsychotics fork of Wernicke-Korsakoff in alcohol misuse disorder. intense cravings. acute psychosis. triggering psychosis. Substance Use Disorder ICD11 CRITERIA • Persistent Use Despite Harm • Impaired Control • Neglecting Responsibilities • Prioritisation • Use in Hazardous Situations • Increased Tolerance • Failure to Reduce Usef Use • Withdrawal Symptoms • Preoccupation with Substance ADHD What Signs/symptoms • Inattention in tasks that are not A neurodevelopmental disorder characterised by 3 traits: impulsivity, stimulating, rewarding or require hyperactivity and inattention. sustained attention • Hyperactivity- physical and mental Diagnosis Treatment • Present in multiple settings • Children- 10-week watchful period, • Evidence before 12 years methylphenidate. Atomoxetine 2 . nd • At least 6 months of symptoms. • Formal assessment • Adults- Methylphenidate or • DDx: Autism,mania. lisdexamfetamine. https://cambspborochildrenshealth.nhs.uk/sleep/ Autism spectrum disorder What Signs/symptoms • As well as 2 key features there may also be A neurodevelopmental disorder characterised by 2 key features: sensory sensitivities, struggle to adapt to new Deficits in reciprocal social interaction and situations and repetitive stereotyped motor restricted, repetitive and inflexible interests. movements. Diagnosis Treatment • Onset in the developmental period but may not be • Multidisciplinary approach- a combination of apparent until social demands exceed limited capacities. environmental adaptations, behavioural therapy and • Formal assessment tools such as ADOS speech therapy. • DDx: Tic disorder, opposition defiant disorder, • Medications like antipsychotics are not mainstay but personality disorder. may be used . Question 2 A Attention Deficit Hyperactivity Disorder A 10-year-old boy is brought to theclinic due to difficulties with social interactions. He appears to not B Generalised Anxiety Disorder be listening, avoiding eye contact. He then sits and repetitively fidgets with the tablecloth for the C Autism Spectrum Disorder consultation. His mum says he struggles with making friends unless they also havean interest in cars. D Obsessive Compulsive Disorder What is the most likelydiagnosis? E Oppositional Defiant Disorder Question 2 Attention Deficit Hyperactivity Disorder A A 10-year-old boy is brought to theclinic due to difficulties with social interactions. He appears to not B Generalised Anxiety Disorder be listening, avoiding eye contact. He then sits and repetitively fidgets with the tablecloth for the Autism Spectrum Disorder C consultation. His mum says he struggles with making friends unless they also have an interest incars. D Obsessive Compulsive Disorder What is the most likelydiagnosis? E Oppositional Defiant Disorder Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Schizophrenia What Signs/symptoms A condition characterised by disturbance of • Positive and negative. • Delusions, disorganised thinking, thought,perception,cognition, self- experience, volition, affect and behaviour. hallucinations, passivity, blunted response, catatonia. Diagnosis Treatment At least 1 month of 2 of the symptoms from the • Co-ordinated by secondary care list above (1 must be from those in bold). • Second generation antipsychotics • Family therapy, individual CBT, arts therapy, crisis DDx: delusional disorder, schizoaffective plan and advanced statements. disorder. • ECT and clozapine SS vs NMS Serotonin Syndrome (SS) Neuroleptic Malignant Syndrome (NMS) Cause Serotonin excess Dopamine receptor blockade Drugs SSRIs, SNRIs, MAOIs, TCAs, MDMA, Antipsychotics (especially 1st gen), linezolid, tramadol metoclopramide Within 24 hours of starting or Days to weeks after starting or Onset combining medications. increasing dose. Lead-pipe rigidity, hyperthermia, Hyperreflexia, clonus, tremor, autonomic instability, altered mental agitation, hyperthermia, diarrhoea, status, elevated CK, bradykinesia, Symptoms sweating, myoclonus, hyperactivity, stupor, delirium, altered tachycardia. consciousness, and autonomic instability. Rule out infection, review medications, Diagnosis Rule out infection, review medications. CK (>1,000), leucocytosis, abnormal LFTs. Stop offending drugs followed by Stop antipsychotics, supportive care- supportive care- benzodiazepines for dantrolene for muscle rigidity, Treatment agitation, active cooling, bromocriptine- dopamine receptor agonist, amantadine if severe and cyproheptadine if severe active cooling. Cooling Yes, if hyperthermic Yes, if hyperthermic Prognosis Typically resolves in <24 hours if May take weeks to recover and treated. potentially fatal if untreated. Schizophrenia Psychosis Mood disorder Mood disorder with Schizoaffective Schizophrenia psychotic features disorder Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Question 3 A 4-6, 6, 1 Fill in thegaps B 2-4, 12, 1 Anti-depressants should start to work for depression within ….. Weeks and continued for C 2-4, 12, 1 ……..months. After initiating a SSRI for depression, patients D 12, 12, 1 aged 18-25should bereviewed after…... Weeks 4-6, 6, 4 for suicidal symptoms. E Question 3 A 4-6, 6, 1 Fill in thegaps B 2-4, 12, 1 Anti-depressants should start to work for depression within ….. Weeks and continued for C 2-4, 12, 1 ……..months. After initiating a SSRI for depression, patients D 12, 12, 1 aged 18-25should bereviewed after…... Weeks 4-6, 6, 4 for suicidal symptoms. E Depression What Signs/symptoms A condition characterised by persistent Anhedonia,anergy and low mood (core), sadness and resultant cognitive, and concentration, low self-esteem, emotional and physical symptoms. hopelessness and guilt, and appetite, weight and sleep disturbance. Diagnosis Treatment • ICD11 criteria at least 2/3 core symptoms plusadditional symptoms for • Patient-led approach at least 2 weeks. • Mild, moderate and severe. +/- presence of psychotic features, anxiety. • Less severe: self-help, CBT, group exercise and • Single, recurrent or dysthymia. mindfulness. • PHQ9, HADS and BDI for at least 2 weeks. • More severe: any: SSRI OR SNRI, CBT, group exercise, • DDx: grief behavioural activation, etc.. Bipolar Affective Disorder Type 1 What Signs/symptoms An episodic mood disorder • Decreased need for sleep, Pressured speech/incomprehensible speech, Flight of ideas, characterised by one or more manic or Distractibility, Increased libido/disinhibition, mixed episodes. Extravagant or impractical plans, Psychotic symptoms Diagnosis Treatment • Functional impairment, hospital admission, lasting ≥7 • Refer to secondary care. Acute phase: haloperidol, olanzapine, days (unless terminated by treatment), with mood and risperidone or quetiapine (mania or mixed episode). If activity increase plus ≥3 of the above symptoms. depressive episode: quetiapine, olanzapine, lamotrigine or • DDx: ADHD, personality disorder, schizophrenia, fluoxetine with olanzapine. • Chronic phase: continue current mania drugs or initiate lithium cyclothymia. https://www.osmosis.org/answers/dig-fast-manic-episode-mnemonic SPOT DIAGNOSIS ”I need to go to the shops because the dogs are in charge, and the government is watching my thoughts through the Schizophrenia microwave, but I can't go outside because the trees might tell my neighbour I'm not real. It’s all because of the electrodactyl vibrations from the couch.” “I’m going to start a new business, no wait ten companies! And I should open a restaurant, and a clothing line, I have so many Bipolar affective ideas! And I didn’t even need to sleep last night, I’ve got so much disorder 1 energy, it’s like the world can’t keep up with me.” Bipolar Affective Disorder What Type 2 Signs/symptoms An episodic mood disorder characterised by Depressive episodes (see previous slide) one or more hypomanic or mixed episodes and hypomanic episodes. and depressive episodes. Diagnosis Treatment • Hypomania: at least 4 days,no hospital • Refer to secondary care. Acute phase: haloperidol, olanzapine, admission, no marked functional risperidone or quetiapine (mania or mixed episode). If depressive episode: quetiapine, olanzapine, lamotrigine or impairment, no psychosis. fluoxetine with olanzapine. • Chronic phase: continue current mania drugs or initiate lithium • DDx: cyclothymia, bipolar type 1,5 MINUTE BREAK Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Generalised Anxiety What Signs/symptoms A condition characterised by excessive worry • Emotional: free-floating anxiety or generalised fear, • Cognitive: brain fog, irritability and fatigue. about multiple aspects of life or general • Physical symptoms: restlessness, sleep disturbance apprehension and the resultant cognitive, and muscle tension. emotional, and physical symptoms. Diagnosis Treatment • ICD-11 6 months for more days than • Self-help → low intensity CBT or psychoeducation → high intensity CBT not • SSRI → SNRI → pregabalin • DDx: depressionwithanxiety, panic • Sertraline firstline disorder, social anxiety disorder. • Short-term benzo if acute crisis Specific Anxiety: Specific Phobias What Signs/symptoms • A condition characterised by excessive and • Emotional: fear response. disproportionate fear centred towards a specific • Cognitive: avoidance behaviour. object or situation with resultantcognitive, • Physical: sympathetic nervous system emotional and physical symptoms. activation. Diagnosis Treatment • Above symptoms classically for 6 months or • Graded exposure therapy 1 linet more. • Short-term benzo for unavoidable • DDx: physiological anxiety, panic disorder, situations. agoraphobia, social anxiety. Question 4 Physiological anxiety A A 22-year-old fourth-year medical student has significant anxiety and fear in themonths leading B Obsessive Compulsive Disorder up to the ISCES. She has recurrent thoughts about failing, feels physically sick, and avoids preparing GAD for the exam including attending ISCE focused C lectures. In her mock, shereported palpitations, D Agoraphobia sweating, and dizziness when entering the exam room. Outside of exam season, she feels fine E Specific Phobia What is the most likelydiagnosis? Question 4 Physiological anxiety A A 22-year-old fourth-year medical student has significant anxiety and fear in the months leading B Obsessive Compulsive Disorder up to the ISCES. She has recurrent thoughts about failing, feels physically sick, and avoids preparing GAD for the exam including attending ISCE-focused C lectures. In her mock, she reported palpitations, D Agoraphobia sweating, and dizziness when entering the exam room. Outside of exam season, she feels fine E Specific Phobia What is the most likelydiagnosis? Panic disorder What Signs/symptoms • Emotional: fear of dying or losing control • A condition characterised by • Physical: sweating, nausea/vomiting, recurrent unexpected panic attacks not restricted to stimuli or situations. dizziness, chest pain and palpitations. • Cognitive: avoidance and anticipation. Diagnosis Treatment • Above symptoms for classically over 1 month • CBT first line • SSRI → imipramine or clomipramine • DDx: GAD, specific phobias, and agoraphobia. • Short - term crisis resolution- benzo Acute stress reaction vs PTSD What Signs/symptoms • ASR – normal transient response with emotional, • Responses to an event (witnessed or somatic, cognitive or behavioural symptoms experienced) either short or long-lasting • PTSD- abnormal response characterised all of the of threatening or horrific nature. following: 1) re-experiencing 2) avoidance 3) persistent perceptions of heightened threat. Diagnosis Treatment • ASR is <1 week (short-lasting) or <4 weeks (long- • ASR- no treatment is needed as it is lasting), PTSD can occur at any time, classically within physiological. 3 months. • DDx: prolonged grief disorder, transient psychotic • PTSD- trauma-focused CBT, EMDR and SSRI disorder, adjustment disorder. or SNRI combination. Question 5 Transient Psychotic Disorder A A 25-year-old reports lowmood and feeling like their lifeis ‘stuck’. 6 months ago they were B Acute Stress Response involved in a traumatic car accident and lost their leg. They can’t stop thinking about it and long for Post Traumatic Stress Disorder C the lifethey used to have wherethey could go running. Sometimes they wake up and pretend D Prolonged Grief Disorder for a moment they have both legs just to feel ‘normal’again. E Depressive episode What is the most likelydiagnosis? Question 5 Transient Psychotic Disorder A A 25-year-old reports lowmood and feeling like their lifeis ‘stuck’. 6 months ago they were B Acute Stress Response involved in a traumatic car accident andlost their leg. They can’t stop thinking about it and long for Post Traumatic Stress Disorder C the lifethey used to have wherethey could go running. Sometimes they wake up and pretend D Prolonged Grief Disorder for a moment they have both legs just to feel ‘normal’again. E Depressive episode What is the most likelydiagnosis? Obsessive Compulsive Disorder What Signs/symptoms • A condition characterised by • Intrusive, unwanted and hard to persistent obsessions and or suppress • Associated with a sense of compulsions. completeness and temporary relief. Diagnosis Treatment • Time – consuming (≥1 hour a day) or result in significant • Severity based distress. 1. CBT - exposure and response therapy • DDx: personality disorders, psychosis, phobia, physiological intrusive thoughts. 2. SSRI → clomipramine. Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Personality disorders What Signs/symptoms • Emotional • A pattern of behaviour that deviates from cultural standards, cause functional impairment and are either • Cognitive • Behavioural due to problems in views of oneself or interpersonal • Poor response to treatment may suggest the relationships. presence of a personality disorder. Diagnosis Treatment • Impact on functioning • Community support • Long-standing patterns- ≥2 years (late • Crisis resolution and home treatment team • Care co-ordinators adolescence/early adulthood) • Psychotherapy including DBT for EUPD • DDx: normality • Pharmacology is notthe primary treatment. -dictionary/emotional-control https://www.essence.com/news/emotional-nudity-8-signs-youre-dealing-emotionally-bankrupt-person/hat-to-do https://www.topdoctors.co.uk/medical- SPOT DIAGNOSIS Their sense of self is in someway contradictory with how others view them Mild Their sense of self becomes incoherent in times of crisis Moderate Under stress, there are extreme distortions in the way they assess Severe situations and their relationships with others. These are accompanied by dissociative states or psychotic-like beliefs like paranoid reactions. There is extreme difficulty acknowledging unwanted emotions and refuses to Severe recognize them In the face of setbacks they give up easily. Moderate Approach to psychiatric conditions Eatingdisorders, Substance use disorders, ADHD, Autism ORGANIC PSYCHOSIS Schizophrenia, Depression with psychosis, Bipolar type 1 Depression, Bipolar MOOD affective disorder Generalized anxiety, OCD, Phobias,PTSD, Acute stress reaction ANXIETY Outliers: Disorders of bodily distress PERSONALITY and chronic fatigue syndrome Disorders associated with physical symptoms Dissociative Disorders of bodily Health anxiety Factitious disorder disorders Neurological Symptom distress Disorder • Presentation • Neurological signs not • Debilitating • Debilitating better explained by Ssymptoms thatEAL FOR THE PERSON despite lack of medical with symptoms concern of having other conditions may vary over time a serious illness.ical signs which are • Associated with brain- • Lack medical signs. • Lack medical signs. intentionally body disconnect induced. Chronic Fatigue Syndrome What 4 key symptoms • TATT A chronic disorder of the nervous system • PEM resulting in severe fatigue lasting at least • Unrefreshing sleep 6 months. • Brain fog • (headaches, tender lymph nodes, myalgia and arthralgia) Diagnosis Treatment • Fukuda, IOM criteria, NICE CKS • Education, pacing activities, work • DDx: depression, BDD (focus is on the adaptations, yearly follow-up symptoms not on the fatigue). • In the past graded exercise therapy and CBT have been advocated for. PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK osceazyofficial osceazy@gmail.com OSCEazy OSCEazy osceazyofficial