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Preclineazy Megan Hodgson DISCLAIMER THIS SESSION DISCUSSES MENTAL HEALTH CONDITIONS INCLUDING: • ANXIETY (INCLUDING OCD) • DEPRESSION • BIPOLAR DISORDER • SCHIZOPHRENIA The information presented in this session is based on UK guidance for these conditions. Individuals diagnosed with these conditions will all have different experiences, which we would not claim to fully represent in this session. We are Medical students, and are not experts on these complex conditions. For official information and guidelines please consult experts in the field. The information presented today is purely for Medical Education purposes only, and should not be used as a generalisation for these conditions. If there are any coincidences in names or condition they were purely coincidental. Any stereotypes or features are based on common presentations. We do not mean to assume or stereotype any of these conditions. Whilst we have done our best to address this topic sensitively, if they do come across as offensive, we sincerely apologise.MENTAL HEALTH & PSYCHIATRY Anxiety Mood Disorders Psychotic Disorders Mental State ExaminationLearning Objectives Describe the principle neurotransmitter systems as they relate to psychiatric symptoms and disorders (Plenary: Neurophysiology/Pharmacology) Describe how pharmacological treatments for anxiety, mood and psychotic disorders influence neurotransmitter physiology (Plenary: Neurophysiology/Pharmacology) Consider the potential for drug interactions in relation to psychotropic medication (Plenary: Neurophysiology/Pharmacology) Describe how drugs of abuse influence neurotransmitter physiology and affect the brain (Plenary: Neurophysiology/Pharmacology) Describe the prevalence and clinical presentation of common psychiatric conditions (CBL) Outline the genetic contribution to common mental illnesses and the major approaches and recent findings to have emerged in psychiatric genetics (CBL) Explain how environmental, psychological and social factors can increase risk and influence the course of mental illnesses at the level of the individual, family, community and wider society (CBL) Describe theories and types of personality and outline how personality can influence the course of disease and its treatment (CBL) Perform a mental state examination (CBL) Evaluate the impact of mental health disorder on an individual (at a functional and emotional level) and those around them (CBL) Describe the importance of a constructive therapeutic relationship with patients and how this is achieved by the community mental health multidisciplinary team (CBL) Mental Health Conditions Anxiety Mood Psychotic Generalised Anxiety Disorder (GAD) Panic Disorder Depression Obsessive Compulsive Disorder (OCD) Mania / Hypomania Schizophrenia Phobias Bipolar Disorder (Types 1&2) Delusional Disorder Agoraphobia Mood Disorders Depression Mania / Hypomania Bipolar Disorder (Types 1&2) Mood: person’s subjective are feeling)w they say they • Blunted Affect – lowered intensity level of emotional expression in emotional situations • Restricted Affect – reduction in range of expression TYPES OF • Flat Affect – no feeling or emotion AFFECT • Labile Affect – rapid & repeating shifts in emotions • Shallow Affect – blunted affect seen in psychopathic individuals Model of Depression Monoamine Model Low Serotonin (happy hormone) in Synaptic Cleft SSRIs: Reduce Serotonin reuptake into pre-synaptic neurone MOAi: decrease breakdown of Serotonin Pre-synaptic Post-synaptic MOA 3 CORE SYMPTOMS: OTHER SYMPTOMS: • Depressed Mood • Decreased/increased sleep DEPRESSION • Anhedonia • Decreased/Increased appetite or weight • Anergia • Poor Concentration / (ICD-10 Criteria) Indecisiveness • Fatigue / loss of energy SYMPTOMS PRESENT FOR: • Agitation of Slower movements • MOST DAYS • Worthlessness or Excessive, Inappropriate Guilt • >2 WEEKS • Suicidal thoughts / acts Depression Severity SUBCLINICAL MILD MODERATE SEVERE AFFECTIVE DISORDER (SAD) 2-4 SYMPTOMS OF 2 CORE 2 CORE 3 CORE ANNUALLY DEPRESSION, 2 OTHER 3-4 OTHER 4+ OTHER RELAPSING ACROSS CORE AND NON-INTENSE MARKED INTENSITY SEVERE INTENSITY DEPRESSIVE OTHER RULE OF 2s ± PSYCHOSIS EPISODES (WINTER) MANIA SYMPTOMS MANIA ABNORMAL, PERSISTENTLY ELEVATED MOOD >1 WEEK WITH 3+ SYMPTOMS BEGINS ABRUPTLY DIG FAST Distractibility MUST AFFECT FUNCTIONAL CAPCITY Irresponsibility Grandiosity Flight of Ideas Activity Increase Sleep Decrease HYPOMANIA Talkativeness >4 DAYS WITH 3+ SYMPTOMS MILDER THAN MANIA DOES NOT: • IMPACT ON SOCIAL/OCCUPATIONAL FUNCTIONING • REQUIRE ADMISSION TO HOSPITAL • HAVE PSYCHOTIC FEATURESBIPOLAR DISORDER Bipolar Type 1 • EPISODES OF LOW & ELEVATED MOOD MANIA + • 2+ EPISODES OF ALTERED MOOD WITH COMPLETE RECOVERY BETWEEN EPISODESEPRESSION VS HYPOMANIA + DEPRESSION • Cyclothymia: high & low emotional mood Bipolar Type 2 changes (less severe than Bipolar disorder)Depression Bipolar Disorder (Type 1) Bipolar Disorder (Type 2)Psychotic Disorders Delusional Disorder Delusion • A fixed, false belief that persists even though there is evidence that the belief is false / the subject of the delusion does not exist • Not explained by racial or cultural beliefs VS • A sensory perception that occurs in the absence of a real stimulus • Auditory hallucinations may be st nd rd 1 , 2 or 3 person Hallucinations SCHIZOPHRENIA POSITIVE & NEGATIVE SYMPTOMS ADDED/INCREASED LOST/DECREASED POSITIVE NEGATIVE EXPERIENCES EXPERIENCES THOUGHT DISORDERS THOUGHT ECHO: HEARING YOUR OWN THOUGHTS REDUCED CONCENTRATION / BREAKS IN THOUGHT INSERTION: THOUGHTS PUT INTO HEAD THOUGHTS THOUGHT THOUGHT BROADCAST: BELIEVING PEOPLE CAN HEAR YOUR THOUGHCATATONIC BEHAVIOUR: DECREASED MOTOR THOUGHT WITHDRAWAL: THOUGHT TAKEN OUT OF HEAD MOVEMENTS DELUSIONS DELUSIONS OF CONTROL: THOUGHTS, FEELINGS OR ACTIONS CONTROLLED BY APATHY / BLUNTING OTHERS DELUSIONAL PERCEPTION: A FALSE BELIEF OF A CONNECTION BETWEESOCIAL WITHDRAWL & ANHEDONIA EVENTS HALLUCINATIONS REDUCED SLEEP CATATONIC BEHAVIOUR: EXAGERATED MUSCLE MOVEMENTS LACK OF PERSONAL HYGEINE Schizophrenia DIAGNOSIS – 1 month+ 1+ of: 2+ of: • Thought echo / insertion / withdrawal • Persistent hallucinations with non- / broadcast affective delusions • Delusions of Control / Delusional • Breaks in train of thought Perception • Catatonic behaviour • Auditory Hallucinations • Apathy/blunting • Implausible Delusions • Loss of Interest/Social Withdrawal Risk Factors STRONGEST RISK FACTOR: FAMILY HISTORY No FHx: 1% Sibling: 10% Parent: 10-15% Monozygotic (identical) twin): 50% nd Mx 2 generation / Atypical Antipsychotic CBT DELUSIONAL DISORDER Delusions • Delusion: a fixed, false belief that persists even though there is evidence that it is false & not explained by racial or cultural beliefs Features of Delusional Disorder • Non-bizarre delusions (could theoretically happen) • No hallucinations, thought disorder, mood disorder or flattening of affect • Present for 1 month+ Anxiety GeneraliPanic Disordersorder (GAD) Obsessive Compulsive Disorder (OCD) Specific Phobias Agoraphobia GENERALISED ANXIETY DISORDER (GAD) CHARACTERISTICS MANAGEMENT Generalised, Persistent, Excessive Worrying Patient Education about GAD & ‘Free-floating’ anxiousness active monitoring Self-help Symptoms: Muscle tension, Fatigue, Psychoeducational groups Difficulty Sleeping, Impaired CBT Concentration, Irritability Drugs: SSRIs (e.g. sertraline), SNRI (duloxetine) Diagnosis of exclusion PANIC DISORDER CHARACTERISTICS MANAGEMENT Recurrent, Primary Panic Attacks CBT Drugs: SSRIs (e.g. sertraline) Symptoms: Referral & Involvement of specialist SNS: Hyperventilation, palpitations, mental health services tremor, sweating, chest pain, N&V, Flushing Psych: derealisation/ depersonalisation, fear of losing control or dying Persistent worry of another attack OBSESSIVE COMPULSIVE DISORDER (OCD) OBSESSIONS & COMPULSIONS OCD DEFINITION Obsession: repetitive unwanted, OCD: Obsessions ± Compulsions, intrusive thoughts, ideas, images, causing functional impairment and impulses or urges distress Compulsion: repetitive behaviours or mental acts an individual feels driven to perform MANAGEMENT Cognitive behavioural therapy (CBT) Exposure and Response Prevention ? (ERP) Drugs (e.g. SSRIs) SPECIFIC PHOBIAS AGORAPHOBIA Recurrent, excessive symptoms of Extreme or irrational fear of entering anxiety certain places or social situations (where escape would be difficult) SNS: Hyperventilation, palpitations, tremor, sweating, chest pain, N&V, Avoidance behaviour Flushing Psych: derealisation/ depersonalisation, fear of losing control or dying Specific stimulus / triggers Anticipation of the trigger in daily lifeMental State Examination • Function: Structured way of describing a patient’s mental state, to help form a more accurate diagnosis • Domains: 1. Appearance and behaviour MSE: 2. Speech 3. Emotions (Mood) KEY POINTS 4. Perceptions 5. Thoughts 6. Insight 7. Cognition MEMORY AID: ASEPTIC Mental State Examination Appearance & Behaviour Speech • General Features (e.g. Weight, evidence of self • Rate (Fast, Slow) harm, IV drug use, build) • Quantity (Excessive, Mute) • Personal Hygiene • Tone (Monotone, Tremoring) • Clothing • Volume • Levels of Consciousness (GCS) • Fluency (Stammering, slurred) • Attitude to Exam: Facial expressions, eye • Preservation (same answer) contact, rapport, engagement, guarding • Repetition Emotions (Mood) Perceptions The processing & interpretation of • Affect (observable emotion) sensory information to understand our • Mood (internal feeling described by surroundings patient) • Hallucinations • Changes over time • Depersonalisation • Derealisation Mental State Examination Thoughts Insight • Stream (poverty of thought) • Form (speed, flight of ideas, • Patient’s ability to understand that they circumstantiality, tangentiality) have a mental health problem and that • Content – ASSESS FOR SELF HARM their experiences are abnormal • Possession (though insertion, • Several mental health conditions → withdrawal or broadcasting) loss of insight Cognition • Orientation: time/place/person • Attention span & concentration levels • Short-term memory (immediate or delayed recall) May require formative assessment Q U E S T I O N 1 You are a medical student with your friend, A GENERALISED ANXIETY DISORDER Laura, out on a walk through the city. Halfway through the walk, she demands you re-route and B PANIC DISORDER finish early. After further questioning her, you realise she thinks a thunder & lightening storm is coming and wants to get home as soon as C OBSESSIVE COMPULSIVE DISORDER possible. You notice she is sweating and looks flushed. For the next week, you ask daily if she D SPECIFIC PHOBIA wants to finish your walking route, but looking at the light clouds outside each day, she refuses to E AGORAPHOBIA leave the house. ANSWER ON THE ZOOM POLL What is the most likely diagnosis? Q U E S T I O N 1 You are a medical student with your friend, A GENERALISED ANXIETY DISORDER Laura, out on a walk through the city. Halfway through the walk, she demands you re-route and B PANIC DISORDER finish early. After further questioning her, you realise she thinks a thunder & lightening storm is coming and wants to get home as soon as C OBSESSIVE COMPULSIVE DISORDER possible. You notice she is sweating and looks flushed. For the next week, you ask daily if she D SPECIFIC PHOBIA wants to finish your walking route, but looking at the light clouds outside each day, she refuses to E AGORAPHOBIA leave the house. KEY LEARNING POINT: SPECIFIC PHOBIAS CAN BE ATTRIBUTED TO A IDENTIFIABLE STIMULUS, What is the most likely diagnosis? WHEREAS GAD & PANIC DISORDER CANNOT Q U E S T I O N 2 A 54-year-old man presents to the GP, complaining of A SUBTHRESHOLD DEPRESSION difficulty sleeping & feeling low for 3 weeks. He explains he has been performing poorly at work, which B MILD DEPRESSION he feels very guilty about, as he is finding he is easily distracted. He also mentions that he has not attended his local gardening group for 2 weeks, despite having C MODERATE DEPRESSION the energy to go, as it is not enjoyable & he has not seen the point in going if he does not feel like eating D SEVERE DEPRESSION the food they are growing this Summer. You suspect this man could be suffering with depression E SEASONAL AFFECTIVE DISORDER What is the most likely severity level of this ANSWER ON THE ZOOM POLL presentation? Q U E S T I O N 2 A 54-year-old man presents to the GP, complaining of A SUBTHRESHOLD DEPRESSION difficulty sleeping & feeling low for 3 weeks. He explains he has been performing poorly at work, which B MILD DEPRESSION he feels very guilty about, as he is finding he is easily distracted. He also mentions that he has not attended his local gardening group for 2 weeks, despite having C MODERATE DEPRESSION the energy to go, as it is not enjoyable & he has not seen the point in going if he does not feel like eating D SEVERE DEPRESSION the food they are growing this Summer. You suspect this man could be suffering with depression E SEASONAL AFFECTIVE DISORDER KEY LEARNING POINT: What is the most likely severity level of this MILD DEPRESSION (2 CORE, 2 OTHER, 2 WEEKS) MODERATE DEPRESSION (2 CORE, 3-4 OTHER) presentation? SEVERE DEPRESSION (3 CORE, 4 OTHERS, ± PSYCHOSIS) Q U E S T I O N 3 You are asked to assess Mrs Savage, a 34-year-old A INSIGHT female, who has been within the psychiatry ward for 3 months, because she has not been speaking to anyone B LABILE AFFECT on the ward for the past month. Midway in explaining her thoughts, she begins looking around and explains she hears ghosts saying that they are going to kill her. C HALLUCINATIONS Initially, she looks very scared of them, but quickly speaks in a joyful tone, happy to see them. She asks to D SCHIZOPHRENIA speak to the doctor to help her ‘get rid of the ghosts’. E DELUSIONAL DISORDER Which of the following is this patient most likely NOT displaying? ANSWER ON THE ZOOM POLL Q U E S T I O N 3 You are asked to assess Mrs Savage, a 34-year-old A INSIGHT female, who has been within the psychiatry ward for 3 months, because she has not been speaking to anyone B LABILE AFFECT on the ward for the past month. Midway in explaining her thoughts, she begins looking around and explains she hears ghosts saying that they are going to kill her. C HALLUCINATIONS Initially, she looks very scared of them, but quickly speaks in a joyful tone, happy to see them. She asks to D SCHIZOPHRENIA speak to the doctor to help her ‘get rid of the ghosts’. E DELUSIONAL DISORDER Which of the following is this patient most likely NOT displaying? KEY LEARNING POINT: DELUSIONAL DISORDER PRESENTS WITH NON-BIZZARE DELUSIONS (COULD THOERETICALLY HAPPEN) PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com