Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay, everybody. Welcome back. Nice to see some familiar names as you can see today. I am coming to you from a corridor. On the other hand, I do seem to have a better connection than I usually have. So apologize if there's people moving back and forth behind me and I apologize for any extra noise. There is there is a slight possibility that I may be called away to um an urgent case. Something's just literally just come up, which is why I've asked for the revision notes and diagrams to be made available to you right from the start of the session instead of at the end. Okay. And you should have access to that are doubly host tells me that that she's organized that for you. Okay. If there's a problem then um Yeah, there it is. It's just come up in the chat. Okay. So, um as usual a reminder that psychiatry lectures can be quite triggering for some people depending on your background. If you feel that you're becoming distressed, then just step away if you want extra help and support with that. Uh probably the easiest way to contact me is through Facebook where you'll find me under my full name, Phyllida Row. That's R O E. Um and my icon there aren't many Phyllida rose, but my icon is a, is a yellow flower. Okay. Don't send a friend request. I never look at them. Send me a message and I'll get back to you within a couple of days. Okay. So we started looking at psychosis last week and you should on your worksheet. Uh You should have 22 pages. One that looks, I don't know how much you can see that that has in the middle of it. Psychosis and the other one again fits more for you. Their management of psychosis. Okay. So what sorts of things try, try just at the beginning to not look at the worksheets. I suggested that you looked up what kinds of things either cause psychosis or have psychosis as a, as a dominant symptoms. So remember psychiatry very difficult to get things wrong in psychiatry. So please, you don't have a go and um join in because if you don't, I'll pick on you. So what sorts of things might be medical problems or psychiatric problems where you're dealing with psychosis as a major symptom, restlessness, yep, restlessness, so especially sleep deprivation, whatever the reason um can cause psychosis. Sleep deprivation is a torture technique that has been used for millennia because it causes psychosis. Okay. What else? Uh I was going to say about uh sometimes, I mean, you know, statistically bad. Annoying. Okay. So paranoia is a type of psychosis. Yes. What else, what else might cause psychosis, Natasha, uh, medications? Exactly which any particular medications? Um, I don't know. I can't think of it right now. That's all right. But you're absolutely right. Medications, prescribed medications, steroids are, um, a particular offender people on high dose steroids. Um, that's something to be very aware of. It usually resolves fairly quickly if you can safely reduce the level of steroids there on. Okay. Um Sharma, who's that? Can we say behavior towards others can also be a second, uh, feeling superior to use. I don't know whether narcissism. Yeah. Those, those are types of psychosis. Okay. We're thinking about things where psychosis is a key symptom. Okay. Abbie Lasha. I'm not sure if that's your first name or surname. What do you think? Oh, Tumbleweed Alina Note sticking firmly on mute. He ba also like alcohol poisoning. Perfect vacation. Yes. Intoxication. Well done. He, but, and what's the opposite of intoxication? You're absolutely right. Addiction withdrawal. Yeah. Okay. So somebody who has been without alcohol who is usually a heavy drinker, usually around about the 48 hour to 72 hour mark, they'll start to withdraw and hallucinations very common usually but not invariably, usually insects or tiny little people or tiny, little bit. So, so they hallucinate small things. Okay. Um And you, mostly your focus of your treatment is actually to prevent them having a seizure. And if you were at the session on seizures, you'll know that the reason for that is that seizures kill. Okay. So your priority in alcohol detox is to prevent those seizures. And you may, well, if the patient is very distressed, you may, we'll give them an antipsychotic. But actually, once the alcohol is out of their system again, usually um those hallucinations disappear pretty quickly. Okay. So you make a, make a decision based around patient distress. Okay. Anything else? Arushi? Sit back. I mean, you guys work um uh seasons like schizophrenia or postpartum, postpartum depression. What sepsis can go sepsis? Yep. So some psychiatric diseases, schizophrenia is the big one. But also as, as you've correctly said, postpartum depression, bipolar disorder, both when the patient is manic and when they're depressed, they can have a psychotic depression. And that's why some people with bipolar disorder are also on long term antipsychotics. So if they have a swing, um they, they've got a little bit of cover already in place for that. Ab Alicia. Can, can you hear us? OK. I know you're, you said your audio is not working. Can you hear us? Yeah, that's fine. Good. All right. Um So if you look at the page with, with just psychosis in the middle um in orange bottom, right, you'll find a list of very short list of psychiatric disease is on the right and a much longer list of medical and organic causes of psychosis So, when I say to you, it's really hard to get things wrong in psychiatry. I'm actually not joking. That's just the first few things that came off the top of my head. If you google it, you'll get endless lists. Okay. So, just be aware, common things especially, but not invariably the elderly frail post anesthetic, they often get knocked off quite badly with that. Any delirium. Again, the elderly are more prone to have psychosis in delirium. But about five years ago now I was in Sierra Leone and I was, um I was delirious. I had uh a colon, Joe Itis. Um And it was, it was, it was very peculiar. I could see furniture changing size, sometimes, absolutely huge, sometimes shrinking down to normal size or a bit small. And I didn't find it frightening. I just thought it was a bit odd that the furniture kept changing size. So don't assume that just because somebody is a bit younger that it's not a delirium and that there isn't psychosis present had I been distressed by it. Somebody would have picked it up because after, after about five days, I did get to where I was, I was working in a very ruhr away area and I didn't get, didn't get to hospital for about five days. Um So rule of thumb is that elderly frail are at higher risk of psychosis from anesthesia, from delirium, uh from um uh any kind of, um I've lost the word um any kind of dementia, especially Lewy body, Lewy body dementia um is a kind of dementia that is specifically associated with visual hallucinations. Um And they tend to see at nighttime things like people coming across the garden trying to climb in windows and things like that. Um So they feel like there are people, they can see people coming towards them and for obvious reasons, find that a very frightening experience. Um Another, so, so epilepsy, we talked about epilepsy as being associated with psychosis. Some unfortunate people have postictal psychosis. For example, alcohol is a common one. Remember that drugs that we prescribe can cause psychosis. And another obvious one to be aware of is that a lot of illegal and recreational drugs also called psychosis. People take them for that for that high that they get from them. Okay. B 12 deficiency where it's 11 to watch out for. Yeah, grief psychosis in normal grieving is not unusual. People will tell you that they can hear the voice or they can see a loved one. This is a normal process. Do not give antipsychotics. I think we've talked when we talked about depression, we talked about how important it is to not disrupt a normal grieving process. Okay. So some of you will have exams coming up. So make sure especially if you've got practical exams, clinical exams, whatever it is you call them for your psychiatry station. Just be aware that you should be able to explain simply just in one or two sentences. Maybe with an example, hallucinations versus pseudo hallucinations and delusions versus illusions. Now, pseudo hallucinations, we haven't really talked about pseudo hallucinations tend to arise for people who have personal personality disorders. Pseudo does not mean the person is faking it. They are very real experience to the patient. What it means is that the hallucinations are generated in what we call internal space. So if you're asking someone about voices, a really useful question is to ask them, does it feel like notice that word feel, does it feel like the voices are inside your head or does it feel like it's someone standing really close behind you talking in your ear? So if they say that they're internally generated, that it feels like someone directly in their head, then that's a pseudo hallucination. They don't respond well to anti psychotics, although you may get some improvement. Okay. So just be aware of that little difference, especially if you know that you've got a psychiatric station coming up. Psychiatric stations are almost invariably much more about how you communicate with the patient and quickly build a relationship with the patient. And it's often said that psychiatric exams are racially biased and the challenge there. And we have to be realistic about that is that people working in a second or third language will not have the communication skills at a level of somebody who is working in a first language. So, what makes psychiatry exams tough for those of you who are taking psychiatry exams from abroad is it's not your race. It's the fact that you're working in a second or third language I can get by in French German and even a bit of Hindi. But I couldn't do my job in any of those languages and I certainly wouldn't pass and examine any of those languages. So, focus on the communication skills in psychiatry. As long as you say, something reasonably sensible, you're probably gonna do all right. Okay. And I promise you, when I tell you, you can't get things wrong in psychiatry. If you, if a six different psychiatrist see a patient, the same patient, they'll come up with six different plans and the chances of those plans working are pretty well the same across the board. Okay. So let's move on to management. And if you've got the paper in front of you on your screen or something like that, let's start with investigations. Okay. So you've got investigations listed out there for you. So the question is why are we doing them? You got somebody who seems to be psychotic. Why are you going to take a glucose level? No trick questions. It's as obvious as it sounds, you don't mess with the list people. So this could be drowsy yours. Uh, it could lead to, uh, Graspers Philip, just coma but not cold before they reach to the three coma, living be some felicitations as we have, the census census will be working properly. Yeah. So check for glucose. You all know how to do a primary six survey. Yeah. A B C D familiar to all of you. Airway, um breathing cardiac disability, everything else when you're doing it for anything. Think A B C D E D E F G don't ever forget glucose. Okay. Glucose is really easily fixed whether it's high or low. Okay. So glucose always and you can just do a finger prick. You don't need to, to send off blood's finger prick is fine. If it's a little bit low standard treatment to bring it up would be a glass of orange juice and biscuit. It's that simple. You give them some sugar. Okay. Why might you do a urine dip for somebody who is psychotic uh reason Julia destructive toxic uses? So I think this one will be toxic to the resource of the brain is um needing to, you're very, you're very fuzzy as uh I'm saying the Julia which is an anti Monje from inside the body, this toxic sense. So if it gets too near on misinterpretation are damaged, deceptively to psychoses. Okay. So you're in depth. What are we looking for on our urine? Dip the amount of a little bit level? Uh nah, now it's really simple. It's really obvious, right? All of these are really easy. Obvious. First thing that comes into your head. Two things that cause psychosis infection and elderly, particularly prone to urinary tract infections and doesn't exclude young people. Okay. But again, easy, quick check for infection and easy, quick check for drugs, which also called psychosis. And that's going to, it's going to affect your management. Which one? It is okay. Why might you want to do an E C G somebody? Not as bad as it is? Great. He joins in and says lots, why, why might you do an E C G for patient's that are psychotic habur just because your name is on my screen? I'm not sure, not sure. It's fine to not be sure. Okay. This one, we're not looking, this is a little bit different. So perhaps it is a bit of a trick question for an E C G. We're not actually looking for a potential cause of psychosis. We need an E C G because if this patient is psychotic and we decide to put them onto an antipsychotic, some antipsychotics come with risk of arrhythmias and things like that. So this is a baseline test to make sure that there isn't anything underlying that hasn't been picked up. Remember, young people in particular can compensate for a lot and so may well have an arrhythmia that their body is living with perfectly well. But if we pick the wrong antipsychotic for them, we're gonna make them ill physically okay. So some of our tests are more about getting a baseline because often, not invariably but often people with psychosis, particularly younger people have had fairly chaotic life and so may not have had basic blood tests and things like that for some time. So it's opportunistic to get those tests in. Well, while we've got them, there will help their general practitioner, it will help guide any ongoing treatment that they have. And for some of them, those baselines are going to be really important. The other thing in investigations to consider, although it's not often deemed necessary is somebody who has no significant history of mental health problems. Um And then in middle life or later life suddenly unpredictably experience um a psychotic episode and that can be caused by space occupying lesion by any kind of internal damage in the brain bleed in the brain, things like that. Okay. So ct head really for people who got through quite a lot of their life with, with absolutely no mental health problems and then quite a rapid onset of problems with no other obvious trigger. Okay. But it's, you know, have it at the back of your head. Do I need to be thinking about something structural happening in the brain? Okay. I've given you a whole big bunch of bloods um in green on the right. So we're just going to quickly run through those and think about, are they baseline? Are they diagnostic? Are they both? Okay? So full blood count, you can always, if you're shy to talk, you can always put things in the cat. Why are we doing a full blood count? Diagnostic als or baseline? Baseline. What about white cell count? What does that tell you? In fact, in the, the infection, infection marker? Yeah. So you're, you're right. It's a baseline. But we're also picking up um whether or not there's an infective process going on that may be causing a delirium rather than a mental health problem. Okay. And anemia. And so we're looking because B 12 in particular and so we won't be 12. Easy to treat. Yeah. And while we're at it and we're doing all of these bloods, we might as well do folate and ferritin as well. And again, it's because often people with mental health problems, their life is chaotic. They may not be eating well, they may not have a good diet. And so you're just checking up that there aren't dietary deficiencies there, okay. And of course, alcohol use can affect folate and B 12 in particular. And so, so, you know, bit of a job lot there. Okay. Use the knee's baseline or diagnostic when I say diagnostic, I mean specifically diagnostic for, for causes of psychosis. Come on, this is psychiatry, you're going to be right. Whatever you say would you would you need that new since mm uh What was the option? You know the baseline before the baseline? Oh, use Annie's um kidney tests and it could be baselines. Yes. A baseline. Yeah. Again, you know, you might, we'll pick up that the patient is dehydrated. Um You might, we'll pick up that they're, that there's some kind of kidney injury going on. But, but mostly in terms of the psychosis, we just want a baseline again because some of our drugs long term can have impact on the kidneys. How about bone? So, bone will usually include calcium and corrected calcium. Why am I looking at those? It could be diagnosed with this? That'd be diagnostic. Okay. Diagnostic of what presence of uh the level of calcium uh is actually one of the importance for the sign up takes listen things. Yeah. Okay. Yeah. So you're looking for electrolyte imbalance. Uh huh. Since you're on a roll here assad, is that your first name or your surname? By the way, that's my first name, first name. Okay. While you're on a roll assad, raised calcium would make you think and worry about what it's a tricky one. Cancer. People with cancer tend to have high calcium levels and parathyroid also tends to give you high calcium levels. Okay. So if you've got high calcium, you're gonna want to be referring on for further specialist investigation. Probably turn out to be nothing bit of dehydration, bit of general imbalance, but definitely beyond the remit of the junior psychiatrist. Okay. Who else is feeling brave? Remember you can always use the chat um, thyroid function tests, baseline diagnostic, both Arushi Nope. Still too shy, not shy. Hmm. Um, diagnostic diagnosis. Yep. Why you're right. Do thyroid problems cause psychosis? Yes. See, psychiatry is so easy. Yeah. Yeah. Psychiatry is 10% knowledge, 90% common sense. Okay. Admittedly the knowledge is pretty rarefied but common sense should be something that you're looking at all the time. Yeah. Thyroid disease, hyperactive thyroid may directly cause psychosis. Or what do we know? Hyperactive thyroid people probably aren't sleeping very much because they've got excessive energy. What does lack of sleep do to you? Clues in the title psychosis? Yeah. So something that causes long term disruption of sleep will cause psychosis. So we're newish mom. He's trying to cope on her own with a baby that is a colicky baby. She might well be sleep deprived. Yeah. Um liver function tests diagnostic or baseline. Natasha. Let's give someone else ago. Natasha. Uh Baseline. Baseline. Yeah. Okay. Um Because some of our medications can be hard on the liver again, you may opportunistically pick things up. But in terms of the psychosis, it's a baseline for following up later. If we decide to start an antipsychotic well done. CLP Abdullah CRP, diagnostic or Baseline or both. Nope, I'm a little bit shy assad, save us all. CRP. I think it would be diagnostic diagnostic because uh this by your back protein function. So it's uh this will be uh inflammatory, it's an inflammatory marker. So it will in combination with your white cell count. It will give you information about whether or not there's infection present, common infections. Most common is urinary tract. Second, most uh most common will be some kind of respiratory infection. Lower respiratory good well done HBA One C Yeah. What does HBA one diabetes baseline or diagnostic baseline. Its baseline. Again, a lot of our drugs cause um what's sometimes called metabolic syndrome. Um A lot of, in fact, pretty well, all antipsychotics will make you hungry. People tend to put on a lot of weight. And so the chances are probably about one in three patient's within five years will develop full blown type two diabetes. Okay. So again, that's something that, that's more about thinking and planning in the medium and long term rather than getting short term control of their psychosis. Okay. Well done though. Vitamin D baseline or diagnostic people. Uh diagnostic. Well, hold on vitamin D. Yeah, I think diagnostic because also uh has a relationship with the thyroid gland. Mm. It's, it's um it's a baseline. Um I always do it because so many people are vitamin D deficient. It's not directly related with psychosis, but anything that makes you feel rubbish is not going to be helpful and it's easily fixed. Okay. So, always opportunistic lick blood's include a vitamin D traditionally, particularly if you live in Northern Europe. It's something that's very much focused on for people who have darker skins. Uh Northern Europe simply doesn't get much sunlight compared to kind of equatorial regions. Um But don't base your decision on whether or on whether or not to do a vitamin D on the color of somebody's skin. I am. With one exception, the weight ist person I know and I managed to get vitamin D deficiency a severe deficiency while I was working in Cornwall, which is our sunniest county. It's right in the south of England. So, especially in cultures where people have darker skins and tend to cover up more. It's a risk. But don't base your decision on whether or not to do vitamin D on ethnicity and cultural background. Prolactin. It's one a bit out of the blue. Anybody like to take a guess on why we need a prolactin. I will tell you now, males and females. This is a baseline. I've heard uh collective collective work works against the moment. Uh If they're collectors in the higher moment, the other homes uh works in. Uh yeah, it's a hormone. Um Most commonly people are aware of it because it does what the name says. Prolactin. It makes milk. It also does a few other things in the body. Males have it as well as females. Antipsychotics can push the levels up as long as people are um are not symptomatic of having high prolactin levels. It's not a huge problem. Long term. It can cause problems with osteoporosis. Both males and females. We measure a baseline so that we can see how big that rise is and we will, if you're on um, an antipsychotic, that's one of the ones that would be checked regularly. Okay. What other disease causes for both males and females? A massive increase in productive. So, this is a hard question. I wouldn't necessarily expect you to know pituitary tumour, which are silent, silent until they start to affect your eyesight. They sit in the cellar that turkey ca just behind your nose. Um, and a massively increased prolactin is an indicator or of a pituitary tumor. Pituitary tumours rarely killed directly but are silent until it's very late. So what you want to make sure is that you can measure the rising productive, okay. Um Normal prolactin in the labs where I work usually is, is below 500. I wouldn't get excited as a psychiatrist until um a prolactin level is reaching 2.5 1,003,000. The quickest way to see whether it's the drug you've given them or whether it is a pituitary problem is to stop the antipsychotic just need to stop for three days. If it's the antipsychotic, the prolactin won't come back to normal, but there will be a significant drop if it doesn't drop, then you need an urgent referral to endocrinology. Normally, endocrinology uh wouldn't be interested to during the 25,030 thousands, but on one occasion in my career and only one occasion in my career, I um I um oh, sorry. No, that's okay. I thought it was a message saying stop. Now. Um, once I've picked up a very early stage pituitary tumor. Okay. So it's worth doing because that's a life changing diagnosis just as psychosis is. And where I'm working at the moment because of the social and environmental circumstances around here, we also routinely do syphilis HIV and as, um, exclusions and HEP B and C again, as, as opportunistic, we have a lot of IV drug users. We have a lot of people with very alternative lifestyles. Okay. This is the only place I've worked where we routinely do those, but I think it's just worth bearing in mind that under some circumstances you, you might want to check those as well. So remember, physical health will always take priority over mental health. Okay. You can't do anything for a patient who is dead. Okay. So you save their life first and then you sort out their psychiatric problems. Okay. So lots of anti psychotics, I could give you a whole spider chart just with antipsychotics on, I'm not going to at your level. What you need to know is that they can be tablets or they can be given as an I M injection and the I M injections are long lasting, depending on the drug and the patient need could be fortnightly, could be monthly. Monthly is, is most common, but for people who are very unwell, it can be done more frequently. And we now have some very long acting ones which are great. We've got one that lasts for three months and now just, just literally come on the market a few months ago, one that last six months. So particularly if you've got a patient who's not great at taking their tablets, you might want to think once they're established and stable, you might want to think about switching them to, to a depo. And certainly if I was unlucky enough to have psychosis that needed long term treatment, my choice would be for a depo for the convenience that I don't have to remember to take a tablet every day or sometimes twice a day. Okay. So it's not just tablets. All antipsychotics require regular physical monitoring. And that's why I gave you that list of bloods for you to think about which of these, our baselines and which of them are actually diagnostic and it's because antipsychotics are hard on the body. Yeah, they come with a lot of side effects. The commonest reason for people being noncompliant with their antipsychotic is because the side effects were unacceptable to them. Okay. So you've got choices, you've got very fast acting ones, you've got longer acting, slower onset ones that are a bit easier on the body. So two basic groups, the typical and the atypicals, there's no evidence that anyone that typical czar better than atypicals in any way and vice versa when you're taking your history, when you're talking to the patient. What you're doing is you're matching side effect risks against patient need. Okay. So, if I've got someone who's really floridly psychotic is really in danger, I will have absolutely no hesitation in starting them with the lands of people which is an atypical, very fast on. It works so fast that you can actually use it for rapid tranquil ization. It's quite sedating. Um, but if you need to get things under control quickly, then it's a good start point for all the elderly frail and for those with learning disabilities, okay. Um elderly frail, I'd be more likely to go for haloperidol, particularly the post anesthesia. The postoperative kind of delirium seems just be aware that if the patient has Parkinson's or Lewy body dementia, you mustn't give haloperidol because there's a risk of causing a Parkinsonian crisis. Okay, respiratory um often very useful for people who have become quite aggressive. Okay. Um And so people with dementia who have become aggressive, tiny doses of respiratory can be quite helpful, could high a pin pretty good antipsychotic, but mostly these days used as a mood stabilizer for people with, with the personality disorders and it's very helpful for them just drawing to a close. Now, a couple of things I want to mention to you um common unwanted effects of antipsychotics. Now we're messing around with the brain, we're messing around, particularly with dopamine receptors, but there's all sorts of other things going on as well. So we're always going to get unwanted effects and it's a question of luck what the patient gets doesn't get okay. Constipation very, very common with antipsychotics treat it seriously every year in the UK, we lose five or six patient's to, um, um, antipsychotic induced constipation, constipation kills. It's not just unpleasant for the patient. Anybody who's had constipation. And I think that's probably all of us knows how unpleasant it is. All right. But just because it's common and mostly pretty unimportant. We a few more veg we go for a walk and it sorts itself out. Okay. Don't dismiss it as unimportant in a patient on antipsychotics, cardiac effects, especially cloZAPine. CloZAPine is your drug of last result. You would only use it really in very treatment resistant schizophrenia because it can cause cardiomyopathy and it has quite a high incidence of cardiomyopathy. Um, lots of our antipsychotics as sedating. And so you have to get a balance between how much of their psychosis a patient can tolerate versus how much sedation. If you're a parent with small Children, you don't want to be very sedated because you need to wake up as the Children need you in the night. If you've got a job that means that you have to be alert and awake, you want to be avoiding them more sedating, antipsychotics, important and you must ask about it because people tend not to volunteer is sexual dysfunction. Okay, hyperprolactinemia. We've already talked a little bit about people, especially in the long term can, can get movement disorders, Akathisia, for example, where they can't stop moving. If you've got a patient in front of you who keeps doing things like that would be, that's a sign of a Cathy zia. Okay. And some patient's experience dizziness, blurred vision, headaches, nausea, again, you know, the list could go on forever. But those are the ones to be very aware of and to specifically explore if you've got a patient in front of me who's on an antipsychotic because maybe one of those unwanted effects, particularly sexual dysfunction and over sedation. They might be why the patient is actually sitting in front of you because they've decided not to take the drug because of that because it's affecting their normal everyday life. Yeah. So remember treating patients' in psychiatry is not just about fixing them in some way, but sometimes you have to be a bit experimental and I'm always open with the patient that I'm hoping this is the right one for you because, but sometimes we need to be a bit experimental because it's not quite right. And that's why I'm asking you about, okay. We've covered a huge amount of ground in these two sessions. I hope you found it useful. I hope you find the notes even in my horrible handwriting helpful as a start point for your own reading. And um, I'm not sure what I'm teaching next term, but I will be doing some teaching. Um, again, so do, do let the team know if there's any particular topics that you'd like covered as, you know, you, you don't get Power Points with me. It's much more like a seminar. So it is harder work for you. But I hope it makes a change from Power Point presentations. So anything you particularly like covered, let the admin t know and um because I haven't booked any sessions in yet, but our booking four or six sessions for next term and uh, we'll see what people want taught. Thank you very much for coming. Whatever time of day it is where you are. I hope what's left of the day is a good day for you. And uh, I'll see you for those of you going into Ramadan, best wishes for those of you heading for Easter again, best wishes and I'll see you in the new term. Thank you so much.