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Psychiatry Mariam Sajjad and Areebah AkhtarWhatwe’llcover • Historytaking • MSE • Explanationstations • Drug counselling • SBARHistories Schizophrenia Low mood Anxiety (headache) Bipolardisorder Eating disorder Risk assessmentLowmood • PC • Hypothyroidism • Openquestions,ICE • Changesinweight • HPC • Feelingcold • Core symptoms • Constipation • Lowmood • OCD • Rituals • Lackofinterest (anhedonia) • Fatigue • Riskassessment • Othersymptoms • PMH • Sleep,appetite changes,concentration,libido • Past medical/psychiatric history • Screenforotherconditions • Dx • Bipolardisorder • Any regularmeds/OTC • Periodsofhighmood/energy(mania) • Any newmeds • Anxiety • Allergies • Uncontrollableworry • SH • Physicalsymptoms(sweaty,palpitations,tremor) • Schizophrenia/psychosis • Effectsondaily life • Smoking,alcohol,recreational drugs • Hallucinations • FH • Delusions • Thoughtdisorders 1. Introducingrisk assessment • ‘I’mgoing toask questions thatarequitesensitive, these are questions we ask everyone.Please let me knowif youfeel uncomfortableat anypoint.’ 2. Thoughts • Thoughts aboutthefuture? • Thoughts thatlife is notworth living? • Triggersfor negative thoughts? 3. Self-harm/suicide • Thoughtaboutselfharm/suicide? Risk • Whenwere thesethoughts? assessment • Have suicide attemptsbeenplanned? 4. Protective factors • Does anything helpwhentheyhave thesethoughts? 5. Risk to others • Thoughtaboutharming others? • Substanceabuse:driving,dependentchildren/elderly • Domesticviolence 6. Risk fromothers • Physicallyhurt? • Takenadvantage of?(financially)Anxiety • PC • HPC • What doyou mean by‘youworry’,whatdoyou worryabout? • Timeline • How hasitprogressed? Hasit gottenworse? • Do theygetsudden‘attacks’of anxiety? • Physical symptoms • in weightons, tremor,sweating, feeling sick,dizziness,dry mouth,insomnia,changes • Discriminate betweenanxiety and otherconditions • Rituals (‘doyou ever feel likeyouhave to docertainthings to relieve youranxiety?’) • you don’t want)hts(‘doyoueverexperienceuncomfortable/distressing thoughtsthat • Lowmood Hallucinations • PC • Riskassess • Openquestions(typicallypresents asa • Have voicesinstructedyoutoself- headachebut hx progresses tohallucination) harm? Harmothers? • ICE • As per risk assessment slide • HPC • Delusions Introduceyour psychreview ‘youseemtobe • Persecution –anyoneouttoget you? undera lot of stress,whenthishappens, an • Mood congruent - depressive(reallyguilty), experience strangesensations’ grandiose • Auditory • Schizophrenic –control, insertion, • Howmany? extraction, echo, broadcasting • Inside/outsidehead? • Mood • Content? –directedtoyou or about you? • Low/high/worried • Visual • Function • What is it? • Constant? • Home: eating,personalhygiene • Family: relationships • Triggers? • Work Differentials • Schistphrenia • 1 ranksymptoms • Hallucinations • broadcasting)ders(insertion, withdrawal, • Delusions • Passivity Hallucinations • Impaired insight • Negativesymptoms • Drug induced • Delirium • PINCHME • Depression • Mania/bipolardisorderBPD/mania • PC • Eitherpresents as high/low mood or delusions • HPC • Low mood • Fatigue,anhedonia, sleep, energy levels, concentration • Askabout periods ofhigh mood • High mood/delusions • Usually grandiosedelusions • Sleep,appetite,energy levels,risky behaviour • Flight of ideas, fastspeech • Impact on function Differentials • Mania/hypomania • Mania> 7 days • Hypomania4-7 days • If delusions/hallucinationspresent =mania • Bipolardisorder Mania • History ofprevious depressiveepisodes • Type1 =mania/depression • Type2 =hypomania/depression • Hyperthyroidism • Substancemisuse • Schizophrenia • Presenceofhallucinations/delusionsEatingdisorders • PC • HPC • What made themcomein? • Describefood intakefora typicalday • Are they onany kindofdiet • Weightchanges,howmuchhave they lost,dotheyweighthemselves (howoften),target weight • How dothey feelabouttheirbody • Bingeingepisodes • Purging(laxativeuse,inducing vomiting) • Physical symptoms • Amenorrhoea,fatigue,constipation, dizziness,palpitations Differentials • Anorexianervosa • Low BMI Eating • Bulimia disorders • Canhavenormal orhighBMI • Cycles ofbingeing andpurgingInvestigations • Bedside • MSE • Physical examination • Bloods (excludeorganic cause) • FBC, U&Es,TFTs, LFTs, glucose,lipids, prolactin • Urine dip/culture • Drug screenManagement Biological Psychological Social Antidepressants CBT+ (traumafocusedCBT) Lifestylechanges;exercise,diet, Antipsychotics ERP (exposure response alcohol + smoking,time off work Moodstabilisers prevention) Educationon condition EMDR Support groups MSE-ASEPTIC • Appearance(+behaviour) • Speech • Emotions • Perception • Thought • Insight • CognitionAppearance(+ behaviour) Perception • Dressed appropriately/hygiene/ clean/ kempt/weight • Illusions:false perception ofa real externalstimulus(e.g.mistaking a shadowfor • Agitated/eye contact/bodylanguage/facial expression/ a person) • Hallucinations:perception inabsenceofanexternalstimulus that thepatient restless/anyabnormal movements believesis real Speech • Pseudo-hallucinations:same ashallucination,but patient knowstheyaren’t real • Rate • Dissociation • Mightspeakfast (pressure ofspeech,flight of ideas),can • Depersonalisation(patient doesn’tfeellike their‘true self’anymore,may bepresentinmania havefeelingof beingoutside themselvesand observingtheirownaction froma distance) • Slow speechassociated withdepression • Derealisation (thinktheworldaround themisnotreal) • Quantity • Povertyof speech→depression • Excessive→mania Thought • Volume • Thoughtform • Quiet→depression • Poverty,pressure,circumstantiality,tangentiality • Loud →mania • Thoughtcontent • Delusions(fixed,false belief) • Rhythm and fluency • Slurredspeech →majordepression,acute intoxication • Obsessions • Stiltedspeech→thoughtblock • Compulsions • Tone • Thoughtpossession • Monotonous →depression,psychosis,autism • Insertion, withdrawal,broadcasting • Tremulous→anxiety • How dothey respondtoquestions? Insight Emotions • Mood iswhat the patientdescribes(subjective) • Dotheybelieve theyhave a psychdisorder? • Affect iswhatyouobserve e.g.bylookingat their • Dotheyunderstandwhat theyare experiencing is abnormal? expression/demeanour(objective) • ‘Doyoufeellike youneedhelp at the moment?’ • Suicide:riskassess(assessriskto self andothers) • Dotheyfeelthey needtreatment andunderstandwhy? Cognition • Orientatedtotime,personand place? • Candoa formalassessment using certaintools (MMSE,AMTS, MOCA)Explanation stations • Conditions • Schizophrenia • Bipolardisorder • Depression/anxiety • Autism • Dementia • Sections • Introduction • ‘As thisif the first time we are meeting, cancanyouupdate mewithwhat hashappenedsofar?’ • ICE • What dothey know already? • What wouldtheylike toknow? Howto • Briefhistory • Structuring theexplanation(chunkandcheck) structurean • What is it? • Whyhavethey got it? (causes/risk factors) explanation • Symptoms(relate it towhatyouhavegatheredinthehistory) • Cover whatthey want toknow station • Management • What cantheydotohelp? (lifestyle,eat/sleepwell, maintainphysicalhealth) • What canwe dotohelp? (bio, psycho, social) • Refer them toa source ofinformation(leaflet, NHS choices) • Any questions? • Section 2 • Section 3 • Section 4 • Section 5 Sectioning • Section 17 underMHA • Section 135 • Section 136 • Explainthat itislegally binding andisfor the patient’s best interest • They canstillhavevisitorsif under a sectionSection 2 Section 5 • Forassessment • 5(2) • Upto28 days • Canbelegallydetainedby a doctor • Non-renewable • 72h • AMHP ornearestrelativemakesapplication onrecommendation of2 • Patient isa voluntary patient inhospital doctors • 5(4) • One of the doctorsshould be approvedundersection12(2)of mental • Nursecandetaina patient healthact (usuallya consultant psychiatrist) • 6h • Treatment can be given against wishesof patient • Patient voluntary patientinhospital • Canappeal within14days Section 17 Section 3 • Supervisedcommunity treatment(community treatment order) • Admissionfortreatment • Canbeusedtorecall patient tohospitalfortreatment if theydon’t • Upto6 months complywithconditionsoforderin community(e.g.complyingwith • Renewable medication) • Applicationmade by AMHPornearest relative on recommendationof 2 doctors(at least 1 section12 approved) Section 135 • Treatment can be given against patient’swishes • Court orderobtainedtoallowpolice tobreakintoa property to • Canappeal atanytime withinfirst 6 months remove a person to aplaceofsafety Section 4 Section 136 • 72hassessment order • Someone foundin apublic space whoappearsto have a mental • Used inemergencies,whereunacceptable delay ingettingsection2 healthdisordercan be takenbypolice toa place ofsafety • GP and AMHP ornearest relative • Canonlybeusedforupto 24h,while a MHAassessment isarranged • Different tosection2asonlyneed 1 doctorrecommendation • Oftenchangedtosection 2afterarrivingtohospital • Can’t be treatedagainst theirwishesundera section4 • Can’t be appealedDrugcounselling • SSRIs • Lithium • Antipsychotics • Introduction • Briefhistory (ofpresentationandsymptoms) • ICE • What dothey understand about the medication, whataretheir mainquestionsregarding it? • PMH Drug • Dx (don’tforgetallergies!) • SH counselling • Smoking, drinking,lifestyle • ATHLETICS structure • Action:howdoesitwork • Timeline: whentotakeit • How totake it(tablet, oralsolution, injectionetc.) • Lengthoftreatment • Effect:howlongit takestowork • Important sideeffects • Contraindications/complications • Supplementary adviceSSRI • Thereis a chemical in the bodycalled serotonin,and when this is low, it can lead to the symptoms you have been Actioneriencing (e.g.low mood) • SSRIs increase thelevels of serotonin in yourbrain to reducethese symptoms Timeline(whentotakeit)eryday • Usuallytaken in morning, as can sometimes affect sleep • Tablet H• Once a day Lengthoftreatmente for at least 6 months after symptoms improve • At least 2 weeks Effects (howlong ittakestowork)rovement around 6 weeks • Ifno improvement after8 weeks → seedoctor, can look at changing to a different antidepressant • No regularmonitoring,can do baseline bloods,ECG,BMI T• If18-24 → review aftera week (increased risk of suicidal thoughts),if > 25 years → review after2 weeks • Can initiallyworsen symptoms and insomnia I• GI upset, insomnia,sexual dysfunction, drymouth, dizziness • Manicphase of BPD C• Poorlycontrolled epilepsyons • Severe hepatic/renal impairment Supplementary adviceddenly(can causewithdrawal type symptoms) • Caution when using NSAIDs (ulcers), triptans,St JohnsSSRI • Thereis a chemical in the bodycalled serotonin,and when this is low, it can lead to the symptoms you have been experiencing (e.g.low mood) • SSRIs increase thelevels of serotonin in yourbrain to reducethese symptoms • Take at sametime everyday • Usuallytaken in morning, as can sometimes affect sleep • Tablet • Once a day • Should continue for at least 6 months after symptoms improve • At least 2 weeks • Should definitely see an improvement around 6 weeks • Ifno improvement after8 weeks → seedoctor, can look at changing to a different antidepressant • No regularmonitoring,can do baseline bloods,ECG,BMI • If18-24 → review aftera week (increased risk of suicidal thoughts),if > 25 years → review after2 weeks • Can initiallyworsen symptoms and insomnia • GI upset, insomnia,sexual dysfunction, drymouth, dizziness • Manicphase of BPD • Poorlycontrolled epilepsy • Severe hepatic/renal impairment • Shouldn’t stop suddenly(can causewithdrawal type symptoms) • Caution when using NSAIDs (ulcers), triptans,St JohnsLithium • BPDcaused bychemical imbalances in the brain Ac• Lithium acts as a mood stabiliser and helps balance these Timeline(whentotakeit) • Taken at night Howtotake itcan also begiven as a liquid) • Drink lots of water • Usuallylong-term, as longas it is controlling theirsymptoms Le• Some people take it for afew years Effects (howlong ittakestowork)ork • Beforestarting: FBC,U&Es, TFTs,BMI, ECG, pregnancytest Tests/mo ito ingerum lithium checked weeklyafter initiation and dose changes (12h after last dose) • Once stable every3 months forfirst yearthen every 6months (also monitorthyroid and renal function every6 months) Important side effectsed appetite,nausea/vomiting,diarrhoea), finetremor,hairloss, polydipsia, polyuria, weight gain Contraindica ions/complicationsmor, confusion, drowsiness,blurred vision,slurred speech,seizures • Toxicitycan be caused by:dehydration, certain meds (ACEi, NSAIDs, diuretics) • Need to make suretheyare drinking enough wateras dehydration can lead to high levels of lithium building up Suppleme tary adviceess → call 111 as can cause dehydration • Given lithium card/monitoring book to show ifneed medical attentionLithium • BPDcaused bychemical imbalances in the brain • Lithium acts as a mood stabiliser and helps balance these • Once a day • Taken at night • Tablet (can also begiven as a liquid) • Drink lots of water • Usuallylong-term, as longas it is controlling theirsymptoms • Some people take it for afew years • Can take several weeks to work • Beforestarting: FBC,U&Es, TFTs,BMI, ECG, pregnancytest • Monitoring serum lithium checked weeklyafter initiation and dose changes (12h after last dose) • Once stable every3 months forfirst yearthen every 6months (also monitorthyroid and renal function every6 months) • GI distress (reduced appetite,nausea/vomiting,diarrhoea), finetremor,hairloss, polydipsia, polyuria, weight gain • Lithium toxicity:coarse tremor, confusion, drowsiness,blurred vision,slurred speech,seizures • Toxicitycan be caused by:dehydration, certain meds (ACEi, NSAIDs, diuretics) • Need to make suretheyare drinking enough wateras dehydration can lead to high levels of lithium building up • Ifinfection/illness → call 111 as can cause dehydration • Given lithium card/monitoring book to show ifneed medical attentionAtypicalantipsychotics • Too much ofa chemical called dopamine,which is causing your symptoms Ac• Thesemedications help to reduce dopamine levels, to improvethese symptoms Timeline(whentotakeit) • Usuallyin evening Howtotake it tablet • Can give depot injection (liquid forms available also) • Long-term Lengthoftreatment • Takes around 2 weeks to work Effec s (howlong ittakestowork)n positive symptoms (hallucinations,delusions) • Can take slightlylongerto seeimprovement in negative symptoms (mood,energylevels etc.) • BMI,ECG,FBC,U&Es,lipids,glucose/HbA1c, prolactin,LFTs Te• Initially may be more regular,then usually annuallyorif changes in dose • Drymouth, dizziness,constipation, blurred vision,drowsiness, weight gain Im• Clozapineassociated with agranulocytosis (monitoring also more regular ifon clozapine,usuallymonthly) • Parkinson’s, Lewy body dementia Co• Prolonged QTs/complications • Increased risk of stroke/VTE Supplementary advicegnant syndromeAtypicalantipsychotics • Too much ofa chemical called dopamine,which is causing your symptoms • Thesemedications help to reduce dopamine levels, to improvethese symptoms • Once a day • Usuallyin evening • Usuallya tablet • Can give depot injection (liquid forms available also) • Long-term • Takes around 2 weeks to work • Initially see improvement in positive symptoms (hallucinations,delusions) • Can take slightlylongerto seeimprovement in negative symptoms (mood,energylevels etc.) • BMI,ECG,FBC,U&Es,lipids,glucose/HbA1c, prolactin,LFTs • Initially may be more regular,then usually annuallyorif changes in dose • Drymouth, dizziness,constipation, blurred vision,drowsiness, weight gain • Clozapineassociated with agranulocytosis (monitoring also more regular ifon clozapine,usuallymonthly) • Parkinson’s, Lewy body dementia • Prolonged QT • Increased risk of stroke/VTE • Neuroleptic malignant syndromeYou are an FY1 doctoron amedicalward. A 28-year-old patienthas been deteriorating. You need to callthemedicalregistrar and use theSBAR formatto communicate the situation effectively. Socialhistory A28-year-old woman, Ms. Emily Carter, D.O.B06/01/1997. NHS no: 12345678wasadmitted • Emilyis agraphicdesignerand describes her jobas"high stress,"particularly overthepastmonth earliertodaywith mildagitation, restlessness,anda headache. Overthepast6hours, her dueto deadlines. Lives aloneinanapartmentandhas limited socialsupportnearby. condition has worsened, with increasedagitation, fever, andmusclestiffness. • Drinks alcohol socially, about2–3glasses ofwineweekly. Smokes 5–6cigarettesperday for the Emilyhad been feeling "onedge"forthepast3days, withrestlessness anddifficultysleeping.She past 6years. Exercises irregularly, mostlywalking on weekends. initiallyattributed hersymptomstostress atwork. Over thepast48hours, shedevelopeda headache, sweating, and shakinghands. She came to A&E after hersymptoms worsened, with episodes ofconfusion andirritability. On admission: shewas notedtobeslightlyagitatedbut cooperative,a low-gradefever (38.0°C) was recorded, andblood tests wereordered, and shewas O/E: admitted forobservation. • Temperature: 39.2°C Since beingadmitted: hertemperaturehas risento39.2°C. Shehas becomeincreasinglyagitated, struggling to follow instructions, and exhibitinginvoluntaryjerkingmovements in herlegs. Nursing • Heart rate: 120bpmtachycardic staffreport shehas beensweating profuselyand is unableto remainstill in bed. No vomiting, diarrhoea, cough, chest pain, orurinarysymptoms werenoted. • Bloodpressure:165/95 mmHg**(hypertensive) • Respiratoryrate: 22 breaths per minute Past Medical History • Oxygen saturation:98% on room air • MajorDepressiveDisorder Examination: • GeneralisedAnxietyDisorder • Reflexes: Brisk, with generalizedhyperreflexia. • IrritableBowelSyndrome • Clonus: Inducible clonusbilaterallyattheankles (3–4beats). Drug History • MuscleTone: Increased tonein all four limbs, with noticeablerigidity. • Sertraline 50mg oncedaily(started 2weeksago) • Cognition: Disorientedtotimeand place, strugglingtofocus onquestions. • Buscopan • Emilyappearsvisiblydistressed, unableto settlein bed. • Paracetamol PRN • Cardiovascular: Tachycardic but regular rhythm, no murmurs. • Norecreationaldruguse • Respiratory: Clear chestonauscultation. • Abdomen: Soft, non-tender, noorganomegaly. FamilyHistory • Father has ahistoryofdepression, treatedwith fluoxetinefor manyyears Questions: • Mother has type2 diabetes and hypertension. Whatis themostlikelydiagnosis? Whatwould you liketheregistrartodo?Situation "Hello, this is Dr.[Your Name],thejunior doctor on the medicalward.I am callingaboutEmily Carter, a28-year-old patient who wasadmitted earlier today. She hasdeveloped increasingagitation,a fever of39.2°C, and musclestiffness.I amconcerned this may be serotonin syndrome.” Background "Emily has ahistory ofmajordepressive disorder and generalized anxiety disorder. Shewasrecently started on sertraline 50mgdaily two weeks ago for worseningdepression. She presented with mild agitation and aheadache buthas sincedeteriorated. Shenow hasfever,hyperreflexia, clonus, and rigidity. She hasno known allergiesand no recent drugor alcoholbinges. There’sno significant family history ofmovement disordersorsudden deaths. Assessment Hercurrent observations signsare: • Pyrexial: temperature: 39.2°C • Tachycardic: heart rate: 120 bpm • Hypertensive: 165/95 mmHg • Tachypnoea: 22 breaths per minute • Oxygen saturation: 98% on roomair On examination: • She appearsdistressed,agitated,and issweating profusely. • Neurologicalexamination showsgeneralized hyperreflexia, bilateral ankle clonus, and muscle rigidity. Sheisdisoriented to time and place. • Cardiovascular and respiratory exams are unremarkable. Recommendation • "I believe Emily is suffering from serotonin syndromeparticularly due to her recent initiation ofsertraline” • I’vestopped the sertralineand started IVfluids to maintain hydration.” • “I have ordered investigationsfor bloods, urinalysis, + ECG” • “I would like to startbenzodiazepines,such aslorazepam,for her agitation and musclerigidity” • “Please could you come and reviewEmily asI am very worried about her condition. Isthere anythingyou would like me to do in the meantime?”SBAR • Serotonin syndrome • Neuroleptic malignant syndrome Serotoninsyndrome Causes? Investigations • SSRIs/SNRIs • Usually clinical diagnosis • Can interactwith StJohn’sWort, tramadol,triptans Management • MAO inhibitors • Discontinuethe causativedrug • TCAs • Supportive care • Ecstasy • IVfluids • Amphetamines • Benzodiazepines(foragitation) How doesitpresent? • Antidotefor severecases → cyproheptadine(5-HT antagonist) • Fast onset(within hrs) • Alteredmentalstate • Agitated, anxious, restless, confused • Autonomic hyperactivity • Hyperthermia,tachycardia,HTN, dilatedpupils, diaphoresis • Neuromuscular abnormalities • Tremor,clonus/myoclonus,hyperreflexia,seizures Neurolepticmalignantsyndrome Causes? Investigations • Usually occurs in responseto introduction oran • CKusually raised(due to musclebreakdown) increasein the dosageof antipsychotics • Renal and LFTs How doesitpresent? • Monitor organ function • Occurs within hoursto days • May develop AKI (secondary to rhabdo) • Hyperthermia • LFTs may be raised • Musclerigidity Management • Stopantipsychotic • Hyporeflexia • Autonomic dysfunction • Transferto medical ward/ICU • HTN, tachycardia, tachypnoea,diaphoresis • Supportive care • Alteredmentalstatus • IVfluids(to preventrenal failure) • Aggressivecoolingmeasures (e.g. cooling blankets) • Benzodiazepines(foragitation andmuscle rigidity) • Dantrolene • Considered in severecases • Skeletal musclerelaxantAnyquestions?