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OK, let's make a start then. Um So today is the psychiatry teaching. My name is Ramea. I'm one of the F two S at Hastings and I just finished my psychiatry rotation last couple of weeks ago. And so today we will be covering depression anxiety, schizophrenia, mental health Act, some of the psychiatric emergencies and some substance misuse, overdose things. Um What we won't be covering today is eating disorders, personality disorders, autism. Um I think the key things that might come up in the B SMS exams are bipolar and the risk assessment especially more so for OS. So I'd recommend going through those two in your own time. We're gonna make a start with depression first. So we're going straight into a question. Um So got a 22 year old male who presents to the GP with four week history of low mood, tearfulness, lack of interest in his usual hobbies, poor appetite and feelings of worthlessness. He denies current suicidal thoughts or thoughts of self harm and denies psychotic symptoms. What is the first line management? Let's start the poll now. Ok. We've only got two answers so far that I can see. Um OK, we'll go to the answer. So the answer for this one is talking therapy. So this is a man that's presented with symptoms of depression. So he's got his low mood, his uh anon and then the other core symptom would be um a lack of energy. And the key thing is that this is going on for more than two weeks. Um So the first line for depression would be low interventional uh cognitive therapy. So things like talking therapy, CBT groups, uh things. Um So Paul you us here is talking therapy likely to involve face to face individual group sessions or online. I think um I think unfortunately, since COVID, most of it has been online or over the phone. Um but and face to face is more, slightly more high intervention now, just because of how much money it cost and how less and less therapists are likely to do in patient in person because it's easier for them. So most of the time for low intervention for a patient like this man would be online, talking therapies or via telephone. And so that would be your first line. Um So we'd start off with talking therapies or CBT or something like that. Low intervention, psychological support. If they're not responding, then that's when we'd step up to uh to biological in your in a biopsychosocial model would then step up to antidepressants. So, such as sertraline at that point. So all of you that answered, did get the right answer here. And the next question is a 79 year old woman is reviewed by the psychiatrist. She is low in energy and mood and has no interest in her usual hobbies. She has its best feeling hopeless. She has reduced appetite and has lost 5 kg in six weeks. She reports disturbed sleep with initial and middle insomnia. So initial insomnia is when you struggle to fall asleep and the middle insomnia is when you wake up in the middle of the night. Um And then you have late phase insomnia as well when you wake up too early and you struggle to fall back asleep. What would be the most appropriate management for this patient and just start the pool the, so ignore that one. So you can see the answers in the other one. Um We've only got one answer so far, but we'll move on. Um So the correct answer for this one is Mirtazapine. So the key things in this scenario compared to the previous example is that this is a much older lady and she is struggling with appetite and sleep disturbance. And in this scenario, we would use Mirtazapine because it's quite um low risk in the elderly population, but it has the beneficial side effects of increasing appetite and causing sedation. So, in this patient, we would use Mirtazapine because that's the most appropriate to address her symptoms. Um And you will see that quite a lot in the geriatric or the old age psychiatry population, right? So looking at depression, you kind of have depression can be a symptom of various different disorders. So you might have unipolar depression where you have one off episode of depression. So that might be major depressive episode or you might have recurrent episodes of that or depression can come under bipolar itself where you've got an episode of depression and a pneumonia. Um And obviously, we won't go through bipolar at uh in this lecture. But it is important to consider if you have a patient with depression to consider screening out for bipolar as well. So depression and this is kind of based on ICD 10 and ICD 11 is a little bit less rigid in how they, uh, like split up the symptoms. But, and based on ICD 10, which is what medical schools are still using at the moment while they could try and catch up. Um, core symptoms are described as anona low mood and low energy and then other symptoms, you might have somatic symptoms. So your sleep disturbance, your appetite issues change in libido and then your cognitive symptoms. So the memory things, the concentration lack of motivation, then you have your psychological symptoms as well. So with your feelings of guilt, worthlessness and hopelessness, in terms of, um, I mean, I gave you one of the answers already, but in terms of if you're in your sy setting or if you're in a real life situation and you're taking a depression history. What else do you need to screen out for? That might not be depression? That might explain the patient's symptoms if you can write your answers in the chat. Yeah. So I gave you one of the answers which was screening for bipolar. What else might you want to consider screening for? Yeah. Perfect nebular. Yeah. Delirium and dementia elderly. Yeah. Any other takers? And this is more. So when you're doing your asking stations, what uh what questions would you need to be asking alongside your depression history? Yeah. Schizophrenia. So your psychosis. Yeah is a big one. Yeah, I'll move on. So you wanna rule out organic causes first and when you look at the ICD, that's the first category of uh like disorders. And the way the ICD is set up is set up in a way that you should be thinking about your differentials in that order. So the first thing you want to rule out is organic causes and depression tends to be the things you'd want to consider in terms of organic is things like your thyroid disease. So are they also having weight gain, hair loss, constipation, cold intolerance alongside the depression, depressive symptoms, things like Vitamin D deficiency b12 folate, all these kind of uh physical things you want to rule out and which is why we always do a set of bloods in every single patient that comes into psychiatry and that include those type of disorders. And you might also be considering things like pla tumors or more sinister things like that. If you have a patient with depression, you need to do a suicidal suicidality risk assessment. So you need to be asking them, do you have thoughts about ending your life? Will you act on that? What's stopping you act on that? These are really important questions to ask um with a depressed patient, you want to rule out anxiety as well because quite commonly they come together and then psychotic symptoms. So like what R said, you want to rule out um if they're having hallucinations or delusions, because as we said earlier, depression might be part of another disorder like bipolar or they might be so severely unwell with their depression and they're now psychotic as well, um which would then automatically require more input, more high intensity treatment than someone who's not. And then, like I said earlier, you'd want to consider bipolar. So you might ask something like, have you had previous episodes where you've been particularly elated more than other people might be. So, yeah, and again, that's really important for oy, more than Katie. So investigations for depressions, you can do your screening questionnaires. So P HQ nine is the main one. but there's quite a few other ones that we would use and then roll out your organic courses, which we've already talked about and depression can be mild, moderate severe. Um, and again, this is more important thinking about how you're gonna manage your patient. So, if they're mildly depressed, like the first patient we had, um, they might have two typical core symptoms and two others. But the main thing is that it's not considerably impairing their life and their ability to function. Whereas moderate, they might have a few more symptoms and they're finding it difficult to continue with their ordinary activities. Whereas severe, they'll have a few, they'll have all the three core symptoms and more symptoms, they might be quite suicidal. They're, they're not functioning at this point. And if they have psychotic symptoms, they're immediately severely depressed and the recurrent is considered two or more episodes. So, in terms of management, if they're mild and this tends to be the cases that go to GP. Um, if they're mildly depressed, then low intervention, low intensity psychological inventions are your first line. So that is your talking therapies. But the issue is with such a long waiting line, uh, waiting list to get on to talking therapies and such a lot of GPS will start anti antidepressants in the meantime as well. But really, you're meant to consider anti antidepressants if the symptoms have been there persistently for more than two years, if they've had a previous episode of moderate or severe depression, because then, you know, that they're likely to become moderately or severe depressed again if they have symptoms, despite the intervention, the low intensity intervention or if that's just what they would prefer, if they're saying I don't have time for talking therapies. I'm not at this stage. I just would prefer medication that is fine as well. Your moderate to severe is when you'd consider your antidepressants and your high intensity. So this might be when you have the face to face um, sessions, that might be more when you have counseling over CBT. Um when you really dig into things that might be causing your depress depression or you might have a longer period of sessions as well. So you typically with your mild talking therapies, it's only six sessions, which isn't quite enough to delve deep into someone that's more severe, um, severely depressed. If they have psychotic symptoms, obviously, you're going to treat that with your antipsychotics. And first line would be OLANZapine, QUEtiapine. If they're so severely depressed, you might consider ECT. So if they're not responding at all to any of the anti depressants we've given or if they're so depressed that they're becoming catatonic, then you might consider ECT. And then here is where you need to consider where who's gonna manage the patient. A lot of the times severely depressed patients won't be picked up by the GP or be picked up by, by A&E S or by the police or by AAA distressed relative calling in. Um And that's the point where you need to consider. Can this patient go home or not? Do they need an inpatient admission? Can they go home with crisis teams? Where do we need to manage them? And again, this is something more oy related as well, um, that you need to consider when you're giving your management plan. So we use the stepped care model to decide where the patients should go. So, step one with your GP practices is to recognize and assess and if they're mildly depressed, you can do it for watching all the low intensity interventions. Or you might consider the medications at that point. If it's slightly more, um depressed, if they're severely depressed, then, but at not at immediate risk of life at risk of life, then you would consider the mental health specialist teams or the crisis teams and they can do more high intensity psychological interventions. But if they're so severely unwell that you might then need to consider inpatient care. Ok. So in terms of antidepressants, we won't go into too much detail into this. But first lines are SSRI s they can take 4 to 6 weeks to take effect and you should continue those for at least six months after remission of symptoms. And it's important to, uh, counsel your patient about the side effects. So your nausea and vomiting, it's the gastro, um, symptoms are really quite, um, a lot more than expected in the first few weeks. And that's something to tell your patient that these symptoms will happen. They kind of have to just get over the hump, it will get better with time. Um And the other thing to notice is that antidepressants are anxiolytic. So you do get a higher rate of suicide in the first two weeks because prior to that, they might have been so numb and so exhausted and too tired to actually carry out the suicide itself. So when they have that lack of anxiety, they then feel more confident to and carry it out. So that's something to make them aware of as well. And like I've had patients say before, they had a sense of clarity in those moments. And those weeks after starting the antidepressants, and there are other lines of antidepressants you can consider. Obviously, we spoke about mirtazapine, which is in its class of its own. We've got um various other ones. The other thing to note I'd say is with amitriptyline. So your tricyclic an antidepressant. Um Obviously, a lot of people use this for pain as well and this is one that's actually very risky in overdose because of the effects it has on the heart. Um it's easier to overdose with and it has higher effects if you do overdose with it. So that's one to be aware of. Yeah, fine. So 22 year old male, same man from earlier comes back following a suicide attempt. He reports six week history of low mood tearfulness. He is depressed. He also reports hearing voices telling him he is worthless. He feels regret that the, um, that he did not succeed and he's still actively suicidal. He is not keen on inpatient admission. What is the most appropriate management? So, just restart the pill. Mhm. Do that. Ok. So we just added another pollen. Now, you think? Ok, we've got four answers. Now, there's not many of you tonight. So I'll move on to the answer. Um, so the answer here would be ad admit until section two. So the first question here is how depressed is this patient? He's come in following a suicide attempt which he regrets and he still feels suicidal. So we can say he's severely suicidal and he's also psychotic. So that automatically makes him severely suicidal. We, yes, sertraline is important, but it's not the main thing here. Sertraline alone is not gonna be enough for this man. Looking at option two, informal admission is not going to work because he's already said he's not keen on an inpatient admission. Um When we're looking at between managing under crisis and admitting it is very fine. Usually between going with either and it's a, it's a very fine line between deciding which way they go. The reason I would say this patient needs to be admitted is because he's actively suicidal. There's a good chance where if you leave him off to go by himself, there's a good chance he'll try again, which is why he needs admission. And then here the question is, do you know your mental health act? And so we'll talk through that. And so your section 52 and, and unfortunately, this is just one of those things you have to learn. Section 52 is a doctor's holding power for 72 hours so that you can hold a patient in the hospital until the responsible clinicians have come and done a mental health assessment on this patient. Section 54 is the same for nurses, but it's only for six hours which is why doctors uh 52 is preferable. Section 135 allows police to enter into a person's home and take them to a place of safety. Section 136 is similar but from a public place to a place of safety and it's important to remember in these scenarios that A&E is a public place as well. Section two, so what's more suitable for this man is um temporary detention of a patient in hospital for assessment and treatment for up to 28 days and the earlier sections we've gone through section five and so you can't appeal by section two, you can appeal and you have to appeal. You have to have your tribunal within seven days. Section three is a treatment order and um that is for a patient to be detained in a psychiatric hospital for assessment and treatment for up to six months and this can be renewed. Um and but that would be down to two clinicians to decide. And again, this can be appealed as well and you have to have tribunal within one month. These are the main ones that you would be expected to know as a medical student. So for your finals, the only other one that I'd say is important as a doctor to know is CTO S so your community treatment order um which is like a section three, but the patients in the community, if they're then not adhering to treatment plan, then you can pull them back in into hospital. OK. So those are the main ones about depression in itself. Are there any questions from that? Ok. We're gonna move into um kinda under depression but sli slightly different a bit more um like SOMA and those kind of non, non physically explain symptoms. I don't remember the exact term, but um this is something that came up in my finals or in my third year exam and it was something that a lot of people struggle to get their head around. So I thought it was important to include. Um So there's a few questions on this. So I'll just start up a pull. OK. So we've got a, what did that go to? So I'll just start a new pe oh I think it's going through. OK, perfect. Um So we've got a 35 year old man presents the clinic with sudden onset paralysis of her right arm following a heated argument with her spouse, physical and neuro exams are unremarkable. Imaging is n ad patient is indifferent about the symptoms. What is the most likely diagnosis here? Oh, no, I do need to create another post. Sorry, I will do that now. Ok. So that's the question up now. OK. So we have a bit of a split here. We have a split between A and D. Um OK, so the answer here is conversion disorder and it is, it is so difficult. Like I hope this makes sense after we're done with a few questions here, but it took my head a while and it was chat GBT that taught me this in the end. Um So this patient has sudden onset paralysis of the right arm. That means that there is almost um like a pattern to symptoms. This is something that absolutely could happen. She could have a stroke or she could have other disorders that can cause one sided paralysis. So it, it follows a pattern here. There's a neurological like symptom and it's not conscious by her side. Then we know that it's come on after a heated argument. So it's caused by psychological distress and there's no findings on any of our investigations. She's also indifferent, which is known as Libel indifference. Um So this would be Conversion Disorder. It's a psychological trauma that's led to neurological like symptoms. There's a pattern to be followed. Um where somatic disorder is a little bit more general and we do have an example of this coming up. It's not really following a pattern for somatic. So we'll go to the next one. So 40 male presents to clinics complaining of severe back pain after a workplace incident, he claims the pain is disabling and prevents him from performing any work related task. And he asked for a doctor's note imaging and exam is normal. He becomes agitated when he's questioned for one of your coworkers has seen him lifting heavy boxes at home over the weekend as well. So let's bring that up. Ok. We've only had one answer so far. Um But I will just answer because maybe it's a bit of a harder one. So this is malingering. Um and malingering is deliver it, exaggeration or fabrication of symptoms for external incentives such as avoiding work or obtaining financial conversation. So this is a man who probably does have back pain. Um But clearly, it's not as bad as he says because he's been observed lifting heavy boxes and he's has an agenda here. He wants that doctor's not. And actually the last time this happened to me was this Sunday that on past, I had a pregnant lady who had clearly uh read up the symptoms of preeclampsia came in saying that she has all these symptoms saying she has headaches, abdominal pain, swelling in her feet and all these things, blurred vision as well. Um But when you examine her, absolutely nothing, there's no swelling. There's no pain when you um, uh, palpate and all her bloods were fine. Her, her preeclampsia bloods were fine and her BP was 125 or whatever. Um, and her, she had no protein in the urine. But throughout the consultation, she was saying, oh, do you think I should go off work? The work won't let me step down my um duties. Would you do a doctor's note? So this does happen a lot. I'd say it happens more outside of psychiatry than it does in, within psychiatry. Because if you're already in a psychiatric hospital, you've already, you, you've already got time off work. And so this does happen a lot and it's important to know the term. Um fine, we'll go on to the next one. So a 32 female presents with multiple complaints including chronic headaches, fatigue, gi discomfort for the past several years. Despite numerous medical consultations, there's no clear organic cause and she expresses significant distress about her symptoms and frequently visits different specialists. What is the answer here? Ok. We've got a bit of a split here between A&E. Um And actually, I would agree. I think either of those could be correct and this is more somatization because there's multiple persistent physical symptoms that affect different organs and they're not explained by a medical condition. The, the main difference I'd say between um A&E here is that the, she's genuinely having all these symptoms and there's genuine distress and she's trying to find the answer for that where hypochondriasis is more, um, they're probably not depressed by the symptom itself, but they are worried about a sinister um diagnosis. Um, but they do very closely linked together as well. Um Yeah. Right. So here's a summary table that chat GBT very kindly made for me. So synotic is caused by psychological distress and it's typically unconscious, but it's multiple vague physical symptoms that don't follow a pattern conversion disorder. On the other hand, again, it psychological distress and is unconscious, but it's neurological like symptoms. It it follows a pattern and that's the main difference here. Um where you could almost think is the, it's this uh stroke or is this GBS or whatever there's a pattern to be followed there. Hypochondriasis is more health anxiety and it's fear of the illness itself as opposed to distress with the symptoms that they're experiencing. And then non chosen is um fabrication of the symptoms. But there's a slight difference between malingering and lung chosen where malingering is looking for a external incentive, like getting off of work or financial incentive. Whereas non chosen is more a psychological reward, they like the attention that comes with it to um whether that's from health professionals or from family. Um So yeah, that I hope that makes more sense with the medica explained symptoms. And like I said, that is a question that's come up with me and is something that can be a bit difficult to get your head around. Ok. We're gonna move on to anxiety disorders now and it's a very quick reminder. Um, obviously, anxiety itself is normal. It's a normal response to threat in danger, but it becomes a mental health problem if it's exaggerated in response to that threat or if it's lasting for three weeks or more or if it's interfering with daily life, it does tend to commonly happen more with females than males. And there's various symptoms. So you might have panic attacks and have things like trembling, sweating, hyperventilation. You might have insomnia, a sense of doom and, and there's loads of different symptoms that will come under anxiety. So various different anxiety disorders and I feel like this is something that medical students ty typically and doctors are more comfortable with. So let's go straight into the questions and OK, 2421 year old female circles with palpitations and worried when having to speak to speak in public or when eating or drinking in front of other people to the point that she avoids doing. So, just bring that up. OK. So we have a few answers for B and social anxiety, which is the correct answer. And yeah, so this patient obviously struggles with social interactions, whether that's presenting or eating in front of others. It's not quite eating disorder just because the fear isn't about eating itself. It's not a fear of the food or the calories or gaining weight. It's a fear of other people watching her eat. So this is social anxiety. Next one is a 45 year old man feels intense anxiety and sense of doom at the idea of leaving his house as he feels something bad will happen. So he has not left his house in one month. Ok? Give you a couple more seconds. OK. So we've got a split between A and C. So either specific phobia or generalized anxiety disorder. The answer here is specific phobia and his specific phobia is agoraphobia. Um Yes, his anxiety is about leaving the house in particular. So that's why it's a specific phobia over generalized. Next one is an 18 year old male who feels on edge often is easily tired, irritable struggles to fall asleep, has a lot of muscle tension, but no specific trigger just open the pole now. OK. So it can we have a bit of a um A split here between A and C. So we've got organic foods or uh generalized anxiety disorder. So, yeah, this, this, yeah. Yeah, you guys call me out on this one. We do need to rule out an organic cause. First, this could be something like hyperthyroidism which does cause anxiety issues with sleep and like a restless energy. So we would need to rule it out. Otherwise, assuming everything is fine, this would be generalized anxiety disorder because he's anxious, but there's no clear trigger for why it's just generally anxious. Then 50 year old female having panic attacks on flashbacks, plus nightmares over the past week after experience experiencing a car crash. Two weeks ago, she has fell on edge since and cannot relax. Ok. So we have a splitt here between PTSD and acute stress disorder. Um So the answer here would be acute stress disorder. And the reason why that is is because um the main thing here is that this event happened two weeks ago. The definition has kind of changed from when I was a medical student, when I was a medical student. It said that acute stress disorder is if the event has happened within three months. And the PTSD is if it's happened more than three months ago, but this has kind of changed since. And so now they're saying ASD is if it's been within a month or so, if it's quite soon after, um whereas PTSD is usually within six months of the trauma, the main difference between the two is how long it lasts. So PTSD would last for more than one month making it chronic, whereas acute stress disorder would be less than one month. So it's transient. Um And the symp the symptoms are similar PTSD, you'd have re experiencing the trauma avoidance of the trauma and that is more specific to PTSD or you'll have hyper. So you're always on edge and feeling like something is gonna happen again with acute stress disorder. You'd have the dissociation really experiencing things for your nightmares and flashbacks and hyperal, but you wouldn't quite have the avoidance. Um, and it is important to know that ICD 11 doesn't even recognize acute stress disorder as a disorder anymore. They wanna do path, they do pathologize um that they really wanna make it normal. The fact that, yeah, you will have emotional distress after a trauma and that is completely normal. That is a human experience. This is not a disorder anymore. Um, the other kind of similar issue to be aware of is adjustment disorder. And the key difference here is that it's a nontraumatic stressor. It's not trauma, it might be a life change such as a divorce or moving town or something like that. It's not a traumatic event in itself. Um, and it usually happens within 1 to 3 months of the, of the stress. Ok. So now we're gonna move on to psychosis. So a 19 year old male presents to A&E with acute onset of auditory hallucinations and delusional beliefs. He reports feeling paranoid and believes that people are conspiring against him. He has no significant medical history and denies substance use. Um, all his examinations and bloods and imaging are normal. His family reports no prior history of psychiatric disorders. Which of the following is the most likely diagnosis. Mhm. We've got one response so far. I'll wait for a couple more. Ok. Um, so everyone's gone for e here first episode psychosis. And that is correct. So firstly, how do we know it's psychosis? We know this man has hallucinations and delusions and, and those are the kind of key symptoms towards psychosis. And the key thing here is that he has no prior history of psychiatric disorders. So it's important to remember that um when we have someone presenting with psychosis, we will label them as first episode psychosis in the first instance. And 20 to 40% of these patients will never have a psychotic episode again. And that is largely due to the impact of early intervention services doing so well at their job to make sure people don't have another relapse. If they then do go on to have another psychotic episode, that's when you can start thinking about diagnoses and you'd classify them into two broad groups. So if you have the nonaffective disorders, so that's where there's no mood component. That's when you can consider things like schizophrenia or persistent delusional disorder. On the other hand, if they do have a mood component, then they might be more considered to be bipolar affective disorder or schizoaffective disorder. And you can consider as well things like depression with psychosis again. Um And that is kind of the main difference between schizophrenia and schizoaffective disorder. Schizoaffective disorder simply has a mood element to it where schizophrenia doesn't, that is the only difference between the two. So psychosis is just a group of illnesses where people lose touch with reality and, and a failure to test that reality. So they're unable to determine whether their experiences are real or not. And you can have both negative and positive symptoms. So let's go into our next question. You are working in a psychiatric ward and asked to see th 30 year old male after he has found immobile in a rigid posture for several hours, he is unresponsive to external stimuli, found grimacing and appears awake but does not move or speak. They note that he has waxy flexibility and psychological pillar and he has a history of schizophrenia and is currently on antipsychotic medication. So, before we go into the question, is anyone happy to answer in the chat? What either waxy flexibility or psychological pillow is ok. Yeah, absolutely. So you're, you're definitely right here, Nebela that these are symptoms of catatonia. Um But does anyone know what you would see if I said that my patient has waxy flexibility? What would you see? No worries, I'll answer. So, waxy flexibility is, let's say you're doing the arm and you're trying to move the arm initially, they'll have quite stiff rigidity and then eventually you move it and it will stay within position. And psychological pillow is quite similar where um if you put your hand under the catatonic patient's head and lift the head up, they will just stay there once you move your hand, it's like they have a magical pillow under the head and they will just stay there because that's how catatonic they are. Now, we'll go on to the question and this is, I'd say the hardest question in, in my set of questions. Um And it's one that probably comes up in like your, um I can't remember what the equivalent of three or eight is in, in fifth year, but it's one of those very, very like detailed kind of questions. So don't worry if you don't get this one and there's no way I would have done this at the time. Um So number 10. OK. So we have a split here between C and D. Um Oh no, no. OK. E as well. OK. Which is not an answer but points for participation. Um OK. C and D are the common one here. And so, so basically, yes, we've identified it's dopamine D2 receptors. Um And the answer here is hyperactivity of the dopamine D2 receptors. And so thinking about psychosis or schizophrenia, even we have positive and negative symptoms. So your positive symptoms are symptoms that are added to a person and this is thought to be due to hyperactive activity. And so think of it as additional activity of the dopamine D2 receptors in the subcortical and limbic region. So these are your hallucinations, your delusions and your catatonia. So these are symptoms are added and the reason catatonia is a positive symptom instead of a negative symptom. A lot of people think catatonia is like severe relaxation, but it's not, it's, it's increased muscle rigidity and stiffness. So it's an added symptom. So that's hyperactivity of the D2 receptors. Negative symptoms. On the other hand, are a loss of usual thoughts or behaviors. And that's hypo functionality of the D one receptors. So you might have effective dis deficient deficits. So you might feel low in mood communication. So you might stop speaking some of the patients relational and social deficits. So a lot of patients, you'll see that they, before they even have uh psychotic symptoms, they'll just become very socially withdrawn. They'll just stop hanging out with their family or friends keep staying in their room and then they might have cognitive deficits as well. Ok. So the next question, 34 year old female presents to the psychiatrist with a belief that the number seven repeatedly appears to her throughout the day on license plates in the newspapers, on clocks. She believes that this is a num this number is a sign that she is destined for something extraordinary and that these occurrences are not coincidental. She experiences this perception as having a special meaning. What is the prominent type of dilution the patient is most likely experiencing? Ok. So we have a few answers. Everyone's gone for a um And that's why I included this one because it is a very fine line between delusions of reference and delusional perception. Um And this would be delusional perception. So, delusions of reference would be something like um on the TV. They were talking about this and they were talking about me this particular scenario. She doesn't think they're talking to her in particular. She's just seeing this one sign and a signing meaning that doesn't exist. So it's kind of like um an illusion instead. So and with an illusion, there is something there, but they're misinterpreting the meaning. So in this scenario, she is seen the number seven and she's misinterpreting the meaning. Whereas in a reference, a delusion of reference, they think that it's directly talking to them. And it's, it's like a one way or two way conversation between them. It's, it's meant for them in particular. And yeah, we're going to the example. So, delusion of reference involves interpreting external events like media or people or surroundings as having personal significance or being directed at the individual. So in this example, very small, sorry. Um so there's a person watching TV, and it says all this content is about me, the TV. The radio, the papers was delusional perception involves the individual misinterpreting an actual perception, like seeing a number um as having a personal extraordinary meaning. So in this example, the lights changed to green, that means that means Boris Johnson has given me the green green light to kill me um to a very slight difference here again, and then obviously, there's other types of delusions that I assume you're more comfortable with. So grandiose, persecutory, paranoid pass passivity and nihilistic. So nihilistic when they believe that everything's dead or dying fine. Um 28 year old male with treatment resistant schizophrenia has been started on cloZAPine, which of the following is the most important aspect of monitoring during the 1st 18 weeks of treatment. Ok. So we've got a bit of a split again here. So um most people have gone for B weekly FBC count for neutrophils in particular. And some people have gone for D which is weekly measurement of fasting blood glucose. And um all of you are right. These are things that we will monitor for everyone. The correct answer here is B because um oh sorry, sorry. Uh No, you've gone for B and D monthly assessment and liver liver function test. So regardless of the right answer here is B because what we are concerned about is low neutrophil count and that's more likely to kill someone first. Um So let's go through it. Um So cloZAPine um is the only psycho antipsychotic shown to have greater efficacy than others. It's the only one that really, really, really works. But unfortunately, it's reserved for treatment resistant schizophrenia because of how many side effects you have. And um you have symptoms like hypersalivation and anticholinergic side effects. But the most important things are agranulocytosis and leukopenia because then if you get unwell septic, you might die. Um And that's why it requires regular monitoring. And in terms of monitoring, you have to do a weekly FBC for 18 weeks and then after that, it becomes every other week and then monthly after one year. Um and it's important to note that levels of cloZAPine can change if you change your levels of smoking. So if you stop or if you reduce it, then your levels of cloZAPine can change. So that again, um important one. KT but also a question that a station that could come up as cloZAPine monitoring uh counseling. So we go back. So in terms of other antipsychotics, you've got your typical, which is your first generation and the most common ones we see are haloperidol Chlo chloroazine. And yeah. Um and these are dopamine receptor antagonist and the main issues with these are the side effects. So you have your extrapyramidal side effects and you can remember those using the pneumonic adapt. So acute dystonia akathisia, pa parkinsonism and tardive dyskinesia. And then you also have other symptoms on top of this. And so the dry skin, the constipation and such atypical to second generation antipsychotics are your first line now and that is because they have reduced side effects. Um And the most common ones are OLANZapine, risperiDONE. Clo cloZAPine is uh again, like we just discussed you for the last resort really. Um And the main symptoms with this is weight gain and metabolic syndrome. Fine. Any questions based on everything we've gone on so far? Ok. So we'll move on to psychiatric emergencies. So, in the chat box, can anyone list examples of psychiatric emergencies that you might have seen or remember? Yeah. So, so neuroleptic malignant syndrome and then Serotonin syndrome. Yeah. Any others I would say those are the two key ones. Definitely delirium TRS. Yeah. Yeah. So those are good answers. Um So there's quite a few, I mean, not as few as other departments I'd say, but quite a few that we can think about. Um And yeah, like I, like I said earlier, neuroleptic Malignant syndrome and serotonin syndrome are probably the most important ones as are overdoses. Um And those are the ones we're gonna cover in this lecture. Um But I think another key one for you guys to know would be alcohol withdrawal because that is something that can kill unlike opioid withdrawal. Ok. So 32 year old male known to mental health services presents to A&E with intense sweating, drowsiness and restlessness. His obs show a raised temperature, raised heart rate, raised respiratory rate, low BP and his thats normal on examination, there's hyporeflexia and myoclonus. He was started a new medication this morning which medication is likely to be ok. So I've got one answer. Um This one person's going for sertraline, which is the correct answer. Um So yeah, in this scenario, we've got Serotonin syndrome, which is excessive five HT transmission causing C NS hyperstimulation and it's categorized by a triad of clinical features. So, neuromuscular excitation, autonomic effects. So we saw that with the um the heart rate and the BP and everything and altered mental status. Um It's usually within 24 hours of starting a precipitant drug or when they're on multiple drugs. So this person has uh started some form of antidepressant basically, which is sertraline and the way you can remember the symptoms is shivers. So shivering, hyperreflexia, myclonus, increased temperature, usually above 41 vital signs, instability. So your autonomic dysregulation encephalopathy later on when it's more serious. Um And that's when you have the loss of consciousness or the altered consciousness, restlessness and sweating. 10 management obviously stop the medication that's causing it and emergency supportive care. So IV fluids and then you can give benzodiazepines and observe for at least six hours. Um And those two are less. Yes. The, the top ones that you'd consider are the the main things. Ok. So next question is a 40 year old man with schizophrenia is brought to the emergency department with fever, muscle rigidity, altered mental status and autonomic stability instability. He was recently started on a high potency. Antipsychotic lab results reveal elevated and leukocytosis. What is the most likely diagnosis? Ok. So we've got one answer for neuroleptic malignant syndrome, which is correct. And so, neuroleptic malignant syndrome is a lifethreatening complication of treatment with usually antipsychotics and is fatal in 10%. Symptoms are hyperthermia, altered mental state rigidity and um libi uh like nervous system liability. So the sweating is usually greasy and then there's hypermetabolism and these are the main differences between the two. So, Serotonin syndrome comes on more acutely. It's within hours of starting the offensive drug. Whereas N MS is more gradual, it's days to weeks. Um in terms of the presentation, it, it is very similar and that makes it a bit difficult. Um But yeah, the greasy um sweat is a giveaway for N MS and then the lead pipe rigidity is also a giveaway and then the reflexes are different. So, hyperreflexia serotonin versus hypo in N MS. Um Yeah, and the management is quite similar as well in terms of stop the offensive agent and IV fluids and yeah, fine. Now we'll move on to overdoses, which is, I think the last section. OK. So 28 year old man is brought to the emergency department after being found unresponsive, he has shallow breathing pinpoint pupils and a decreased level of consciousness. His friends report that he is a known IV drug user. What is the most appropriate antidote? OK. OK. And again, um I definitely had a question on overdoses and the antidotes in fifth year and it's quite a in uh not an easy one. Unfortunately, it's one that you have to wrote then again. Um but there's so many variations of an overdose question. So it's kind of, it's quite high yield question. OK. So we've had a few answers for naloxone which is correct. So here we know that the shallow breathing pinpoint pupils, which is usually the giveaway for um opioid overdose and decreased levels of consciousness. And we know he's an IV drug user as well. So there's a good chance he's had an overdose of heroin. Um and which the antidote is naloxone. So you'd give 5 400 mcg of the first dose and then you can step it up. Um Again, this is another one that's very fair game and not oy in your at e initial assessment and and also something fair game for an F one to be expected to be able to manage. Um Obviously, in the sy, you would still say escalate to senior support. But um yeah, this is definitely fair game and obviously a lot of F ones will have a geriatric job and this is something that will happen a lot with the patients with morphine and where you start to question this. And then yeah, you'd have to ask for the naloxone. Um Don't worry too much about knowing the doses and a oy situation. You can just say check first guidelines um or check the NF OK. Next question is a 35 year old female who's brought into A&E after being found unconscious at home, her husband reports she has been having insomnia and was prescribed some sleeping tablets last month on examination. She has drowsiness, slurred speech and respiratory depression. What is the most appropriate antidote? Ok, so we have a few answers for a and a few answers for e so this one is a um so we've got sleeping tablets, dilated pupils and respiratory depression. This is most likely benzodiazepines, um which you can tell by the dilated pupils and the respiratory depression. And that's kind of, yeah, the main benzos and opioids are your main two overdoses. Um And that's the main difference that I would focus on dilated pupils versus pinpoint and the antidote for this is flume, flume. Um And again, it's just something you have to learn, unfortunately. Ok. 50 year old man presents to the emergency department after an intentional overdose of his prescribed propranolol. He is hypertensive bradycardic and complains of dizziness and shortness of breath. What is the most appropriate antidote? Ok. So we have a split again between C and D. So this patient has a beta blocker overdose. We know that because it tells us propranolol. Um And usually they would tell you for this type of question II, it would be difficult for you to be able to guess without knowing uh based on the symptoms alone. And again, just rote learning the antidote for beta blockers is Glucagon. Um Yeah, I think this was the question I had in my finals. It's definitely Glucagon and I, and I remember that because it's just so random. Why is it Glucagon? Um Yeah. Again, thro learning, next question is a 40 year old woman presents to the emergency department after ingesting a large amount of amitriptyline tablets in a suicide attempt. She is confused has dry mucous membranes and is exhibiting tachycardia hypertension and wide widened QR S complexes on the ECG again. What is the antidote? Wait for a couple more answers to come in. I I'd advise you to just guess regardless, cos that's what you're gonna have to do in the finals. Um and it helps to just commit to an answer. OK. So we have a few answers for E which is correct. Um So sodium bicarbonate is given for amitriptyline overdose and this is works in the same way as an any other antidote, but it also helps to alkalize the urine and correct the widened QR S complex by stabilizing the cardiac membrane. Um So yeah, 25 year old female presents to emergency department after intentionally overdosing on paracetamol in a suicide attempt, she reports taking approximately 20 tablets of 500 mg each six hours ago. Lab results show elevated liver enzyme level and she has mild jaundice. What is the most appropriate initial management for this patient? This is your last question of the night? OK. So we have a few answers for C which is administered NAC which is correct. So you would consider activated charcoal if it's within one hour of the overdose, that doesn't typically happen in practice though it usually is a few hours later. So paracetamol overdose and typically when you're giving a dose to your patient. It's um 1 g, four times a day daily and 4 g. Uh max in a day, sorry. Um And let's practice for paracetamol overdose. The main ones that you'd need to remember is obviously um psychological history. If there is known to be self arm or someone that's gonna try to attempt suicide before both of the low body weight and especially in your elderly population, a lot of them will be below 50 kg. And that's when you need to consider halving the dose of that, you're prescribing early symptoms. Um within 12 hours, they might be asymptomatic or they might have general nausea, vomiting or abdo pain. And later symptoms would be more severe pain, metabolic acidosis, the jaundice. So really your liver is starting to be affected at this point and you can lead to coma or coagulopathy. Your investigations would be paracetamol concentration. LFT S are the main one I nr um and then you can consider some other ones and there are different various uh management plans based on how long they took it. And did they take in a staggered dose, various levels amounts, et cetera. But really, all you need to be able to say is that that ii either activated charcoal within one hour or N A. That's all you really need to know to say. And you can just say, uh check plus guidelines. So that's paracetamol overdose. Any questions I have chosen the harder parts of psychiatry to focus on. I think a lot of people assume it's easy and a lot of it is easy. I think. Um I try to focus on the harder things that people struggle a bit more on. So if there are, if you did find the questions difficult, that's, that, that's completely fair enough because I did try to make it hard. Um But yeah, let me know if there's any questions, I'm gonna send the feedback form as well. Thank you, Paul. OK. I think there's no questions, so I'm gonna end the session. Um And yeah, please provide feedback.