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Take some time. Nice. It's hi, everyone. Welcome back to the five academic revision tutorials. Today is the last session of the series will be covering psychiatry and we're very lucky to be joined by Suzanne, a final year medical student over to you, Suzanne. Hi, everyone. Um Can someone just message in the chat if they can hear me? All right, brilliant. Um So thanks Lucas for introducing me. Um Welcome to the Psychiatry, your vision tutorial. Um So I guess we'll get started. Uh the way that the session is going to work is that um it's a series of high yield um multiple choice questions and um they're based around seven clinical cases. Uh So we'll just get started with the first one if that's okay. And then I've got poles with all the answers. So I'll launch the pole and then you can select the answer that you want to, right? So these are just some resources um for kind of further study. Um Yeah, if you're interested. So this is our first case. So we've got Mark. He's 30 T and he's presenting to his GP with two months of low mid, he's unable to say what he enjoys doing and no longer plays football or golf, which he used to do regularly. He also feels that he has no energy and feels tired, which he's putting down two per sleep and his relationship is breaking down due to his loss of interest, insects, which is causing strain on him. So the first question would be in line with I C D 10 criteria which two of the following symptoms are considered associated symptoms rather than core symptoms of depression. Can you see people? Great, great. So I'm not actually sure if you can select two answers at once. Can you or are you just picking one? Just one grand? Well, the most popular answers are actually the correct ones. So you're right at sleep disturbance and reduced appetite. So they would be associated symptoms with depression, whereas the sort of triad of core symptoms that you need to remember would be low mood anhedonia and fatigue. So I would just commit that to memory. Great. So, um the next question would be assuming that he had no additional symptoms. Um How would you classify this episode under the I C D 10 criteria? And this is important because depending on how it's classified, then the treatment will obviously be different. Okay. So this one's had a bit of a mixed response. Um The answer is actually mild depression um based on the I C D 10 criteria. Um I'll explain why in a second there's another information slide, but basically for it to be moderate or severe, um you need to have sort of either more of the core symptoms or more associated symptoms along with it. Um So this would be classed as mild depression, which means that um you wouldn't be offering antidepressants as your first line treatment if that makes sense. And obviously it's not depression with psychosis because there's no psychotic features like hallucinations or delusions. Okay. So the G P refers mark for CBT. So that's because it's a mild depressive illness. But due to the long waiting list, she also decides to prescribe an antidepressant. So in his past history, um he's got a F and he's taking amiodarone um for pill in the pocket treatment. So of the following treatments um which would be completely contraindicated if he's on amiodarone. Ok. That's brilliant. Most people are going for the crack dancer. So the cracked answers Citalopram. Can anyone tell me why? Why would it be Citalopram and not sertraline? For example, that's completely contraindicated. Yeah, absolutely. That's right. Um So um SSRI can all prolong your Q T C, but Citalopram particularly is the most dangerous and it's actually a life threatening combination if you were to prescribe amiodarone along with the Citalopram. Um because it'll prolong your Q T C and then it will eventually lead to torsades, which is obviously, you know, can be fatal. Um So brilliant. Well, well picked up on that one So in the first instance, if you were going to prescribe an antidepressant, what would be the most appropriate one of the following to prescribe? Yeah, brilliant. So um we go with FLUoxetine, FLUoxetine here cause obviously we're not going to give them Citalopram, put these on amiodarone. Um But we probably go with FLUoxetine anyway, um you always start out with an SSRI where possible. So, Venlafaxine isn't right because that's not necessary. It's an SNRI mirtazapine is also different class and amitriptyline is a tricyclic. So you wouldn't be going for those as a first option. Does that make sense? So then I just got a few more info, information slides about depression in general. So the core symptoms, the sort of triad of low mood anhedonia and fatigue, I would just commit that to memory and then all the associated symptoms down the side that are kind of self explanatory when you think that someone's low in mood, so disturbed sleep per concentration, low self esteem, appetite changes. So that can be um typically appetite decreases. But in a typical depression, your appetite can increase, obviously, suicidal thoughts, um um slowing of movements, guilt, self blame. Um and then with depression with sort of psychotic features, um you could have sort of a delusional guilt. Um And usually if you're having delusions with, you know, quite severe depression, the delusions will tend to be a mood to congruent. So that means that if you've got a depressed mood, then your delusions will also have a sort of depressive nature. Like, for example, people can have, you know, beliefs that sort of pathological guilt, um or belief that, you know, their bodies rotting or that they're not, they're not actually there, but those delusions will tend to be negative if that makes sense. And then this table um sort of explains what I was saying earlier about how you classify between mild, moderate and severe. Um So it's based on the criteria um but you can see next to it. So with core symptoms and then how, how many associated symptoms you have as well. So basically between mild, moderate and severe, um it's just based on symptom burden and how badly it's affecting your patient. And then a bit more information about antidepressants. So obviously, they're given for depression, but they're also given for a range of different anxiety disorders for anxiety, PTSD OCD, the doses tend to be higher. Um But as I said, and they're very effective treatments, but as I said before, they're not first line for mild depression. So that would be CBT. And I think it's worth just having a look at what CBT actually involved just so that um you're prepared, you know, even for our skis or for um exams just to know roughly what it is and be able to give a sentence or two about um what the treatment actually entails. Um So this is just more about prescribing information. Um first line for depression would be an SSRI. So, uh actually you would, if that wasn't working, you would try and increase the dose and if that still wasn't working, you would change to another medicine within that same class. So another SSRI um if that then wasn't successful, you would think about switching classes and that would be based on sort of side effect profiles and things as well. So for example, um say you had a patient who absolutely couldn't sleep and had lost stones and stones of weight, then you might think about something like Mirtazapine because that has um those are side effects of Mirtazapine and you would be able to help with those specific issues, but it wouldn't be your first line treatment for um sort of barn door depression. Um And then if your third line drugs don't work, then you can think about augmenting with lithium or older drugs. And then in in treatment resistant case is you would use E C T. So this is just going to be a bit of a quick fire. Um I couldn't make a pool for this. So um if you could just write in the chat, the um class of treatment that is associated with each of the following side effects. So if we start with a um we got gi upset sexual dysfunction, hyponatremia um which class of treatments for depression cause that side effect profile. Yeah, SSRI is brilliant. Next one weight gain and sedation. I kind of gave away the answer to this earlier. Yeah, it has been excellent. Um, and also, uh, tricyclics can cause sedation and wake in as well. High risk and overdose. Mhm. Yep. Brilliant. Hypertensive crisis. Oh, yes. So, I'm sorry, I didn't see the answer someone's written. Yeah, MAOI. Um, brilliant. And is there anything in particular that would provoke a hypertensive crisis if you were taking an MAOI cheese? Yeah, exactly. So, um there's a, there's lots of different things that can cause that reaction. Um But it's basically uh yeah, tyrosine. Exactly. So things like cheeses, yeasts, fermented foods, um stuff like Kimchi wouldn't be recommended. Um But if you were going to be examined on this, it would usually, you know, it's usually food related. Um and it'll be apparent in, you know, that in the question or in the stem. Um You can see examples on, on past med and things. Um, you know, so and so had a cheese board and then they had this reaction grant and then lastly confusion and my algia it doesn't have to be a drug. Yeah. Brilliant. E C T. Um And that sort of expected. Um And patient's will be counseled about that before they go in free ct that they might have uh they might feel slightly confused afterwards. Um And they might have some muscle aches as well. Grant. So we'll move on to case to. So this next case is Shelly who's 38. So she presents to mental health services. Um and her husband has noticed that she's been behaving inappropriately. So jumping on his bosses back when he was around for dinner and that's completely out of character for her. Um She started some new projects which are going to end world hunger, but she hasn't been able to complete any of them. And these tasks have distracted her from picking up her Children from school on multiple occasions, she doesn't sleep, but she still has an elated mood with high energy. Um And then her husband tries to talk to her about it. She's very irritable and unkind. So based on her symptoms, what do you think is your initial diagnosis? Ok. Brilliant. Most people have gone with the right answer. So this is a manic episode. Um Why would you say manic and not hypomanic? It is a manic episode but just to make sure that you're clear on the difference between the two, if I go back to the presentation effect on function. Yeah. Um That would be a good way of thinking about it. There isn't actually a time course given in the question stem here, but also you could do it based on time. Um So if it's gone on for longer than a week, um that could also be classified as, as mania. But in this case, it would be to do with just the extent of the symptoms and um I mean, jumping on our bosses back and interfering with her life, you know, she's not picking up her Children from school, she's barely sleeping. Um So again, it's about how much it's affecting your patient. Basically. Grant. Um So some people had gone for um hypomania. So that would be um similar symptoms but to a less severe extent if that makes sense. Um And schizophrenia, I wouldn't say this is, um it doesn't say anything about sort of uh delusional beliefs or hallucinations. Um So that's why I would, I wouldn't, I wouldn't go for schizophrenia in this instance. Um If that makes sense, okay. So this next question is about her speech. So you notice that her speech is very pressured when you're speaking to her and at times she struggled to follow her sentences. She's speaking quickly, but she's taking a long time to answer your questions and is often including lots of unnecessary information. So of the following terms, which sort of best describes her speech. Yeah, interesting. So this one has a bit more of a mixed response. Um The answer is the most popular one. So it, this is circumstantiality. Um And the reason it's circumstantiality is because the end goal is still reached. So a way of thinking of circumstantiality is someone will tell you more information than you need to know. They might go a very roundabout way of telling you your answer, but you will get an answer and it will be, you know, the answer to the question you've asked. So, in this question, she takes a long time to answer your question fully, but she does answer the question. Um, so that circumstantiality, flight of ideas would be, she doesn't necessarily get to your, to the answer. Um, you know, she's talking and then she go off on, on another idea. Um, and it'll be sped up. Um, tangentiality is, um, also called, um, Nights Move Thinking. So that's whenever, um, someone completely, you know, they might start and then they'll go off on a tangent and they'll never come back. They're just, their thoughts will be sort of derailed. Um, and then word salad is when you basically can't make sense of what someone's saying. Um, and it just sounds like gobbledygook and you can't discern, um, any meaning from it. Does that make sense of why, why the others aren't? Right? And why it's, it's circumstantiality. This actually took me a long time to get into my head. So, um, one thing I could recommend is just to go on youtube and there's loads of people who made videos about this and they give examples of people speaking in each of the, each of the styles. So they'll, they'll show someone who's speaking in a very circumstantial way, um, just giving in lots of unnecessary information into the story, but still reaching, you know, the final end goal. Um, and then they'll show someone with tangential speech or someone with a flight of ideas grand. So assuming she's got bipolar. That's kind of what we're, what we're assuming because she's manic at the minute. Um, what would be the most appropriate treatment at the moment? Okay. Again, there's a lot of a mix here, but most people have got it right. So the answer is good typing. Um, just because this is acute mania rather than maintenance therapy for, for bipolar. Um So you can use, can type in for, for maintenance as well. But um in acute mania, you would use an antipsychotic like typing or OLANZapine. Um um and lithium, you can use lithium acutely, but only if the patient's already taking lithium. Um So if they're on lithium and their mood goes high, then you might need to increase the dose. For example, you wouldn't give FLUoxetine because that's an antidepressant and that will make their mood go higher. Um If you imagine it's trying to combat depression, so it's going to increase your, your mood. Um evaporating carBAMazepine are also maintenance treatments, but there um second or third line. So that's why they're not correct and why um acutely acutely you'd use an antipsychotic like typing and then this is kind of alluding to what I was speaking about earlier, but um which of the following would be indicative of mania rather than hypomania brilliant. So most people have answers. Um I've got it right. So it's um auditory hallucinations. Um and that would be um a differentiating factor between someone who's manic and someone who's hyper manic. Um Similarly with um depression or other sort of mood disorders, hallucis, hallucinations and delusional beliefs tend to be mood congruent. So, um people who are manic might have delusions of grandeur, you know, like, oh, I'm so important. I've been given a special message because I'm, you know, super important and super um influential. Um and they're hallucinations might be reflective this as well. So they might, you know, hear voices of, of, you know, praise or people telling them they're wonderful, but it's, it'll be congruent to their mid if that makes sense. Um Sexual promiscuity, you can have that with um hyper mania as well. Um Insomnia can be universal as well. Um The thing with bipolar is that they, they won't be sleeping but they won't feel tired. Um So that's kind of a differentiating, differentiating feed uh feature, they'll feel less need for sleep. So that's why they're not sleeping. It's not that they can't like someone with depression for example. Um And then irritability and per attention span can be with, with either mania or hypomania. This next one is about side effects of lithium treatment I would recommend um just having a look at lithium side effects. Um Also on, I forget what it's called. What's that website called that has the or ski stations on it. Geeky medics eat Gigi medics. I think it's called documents. Um They have practice are ski stations and there's a really good station on lithium counseling, um which I'd recommend looking at. Um you know, even if it doesn't get asked in the exam, it's still just, just generally good to know. Brilliant. So everyone's picked up on this. Um so fine tremor, renal impairment, teratogenicity and thirst, they're all side effects of lithium, but neutropenia isn't grant, this is another side effect option. So, um she started on the Motrin gene for prophylaxis. Um but she develops a maculopapular rash with concentric circles um and a bliss and blisters on her lips. So, what is the best management option? And can anyone tell me what the name of the rashes? Does anyone know what the rash is called? That's been described there? The blistering rash. Yeah. Brilliant Steven Johnson syndrome. Yeah. Excellent, great. Um So the answer to this question, it's kind of, I mean, there's kind of a split within the answer is whether you should gradually withdraw the lamoTRIgine or whether you should discontinue it. Um You should discontinue it pretty quickly because um Steven Johnson syndrome, it's an acute blistering rash. But um there's a sort of continuum between Steven Johnson syndrome and 10. Um So in this instance, you'd want to discontinue it as quickly as possible so that it doesn't progress any further. Um grant but well, well identified. So this is I just differentiates between um depression and bipolar. So uh depression is more common in women. Um, and there's a higher lifetime risk than for bipolar. Um, I didn't realize this before, but bipolar is actually equal between, um, between the sexes and then ages of presentations, um, tend to differ as well. And I put this one is just here to remind you not to pigeonhole your patient's, um, with something like psychiatry as well because, um, mental health is sort of, I think less understood in many ways than other aspects of medicine. Um And you want to make sense of everything and be objective um into how you classify people. You need, just need to bear in mind that actually people can have multiple things wrong with them at the wrong, multiple things going on at the same time, you know, someone can have schizophrenia and also be depressed. Um anxious people can often have depression as well. Um So there, there can often be overlap within um different conditions and just not to pigeonhole someone into a diagnosis if it doesn't necessarily reflect um what's going on grant. And then this is a bit more about bipolar. So just to define bipolar, you need to have two episodes of mid change and at least one of them needs to be either a mixed state or some kind of period of high mood. So that whether that's mania or hypomania. Um and it sort of makes sense because if someone was just having recurrent mid changes, but they were all depressive in nature than you would consider it depression rather than bipolar. You know, to have a diagnosis of bipolar, at least one of those periods needs to be a higher mid. And then with bipolar as well, the changes in mood tend to be a bit more sustained. Um So you could have sort of months of stability and then have a manic episode, for example, or um you know, have months of depressed, being depressed and then you go back to sort of state of normality and then you go higher, then you go back down to being low again. Um But it's not as if, you know, every day, um your mood is fluctuating all the time, it's more stable than that if that makes sense and the changes are more sustained grant. This is a little bit more information about therapies for um both acute and long term management of bipolar. So for a manic episode, you'd obviously stop anything that was going to send their mood higher like antidepressants. And if they're already on existing therapy, for example, if they're already on lithium, then um make sure that they're on an optimal dose. If they're not, then you would start an antipsychotic. So something like type in a land spine and then uh you can add on lithium if that doesn't work again. Similarly, for depression, um if they're on an existing therapy therapy, then you would optimize it. And um if not then you'd give an SSRI to combat the depression, but you also give an antipsychotic as well. Just so obviously, the SSRI is gonna hopefully increase their mood. Um And with someone who has bipolar, you don't want to send them too high, you don't want to send them into a manic episode. So that's why you would add on the anti psychotic as well. And then long term, um, lithium is first line for long term management, but it's not appropriate for every patient just because um it's a drug that has a very delicate balance. And if your patient is going to be lost to follow up or you don't think that they're going to adhere to it long term, then it's a bit futile to start them on lithium just because you need to be able to come for bloods to be tested, to come for blood tests and um be, you know, in the area. So someone's going to move to another health board, you wouldn't necessarily start them on lithium either unless you were sure that they could have continuity of care wherever they went. Um Grand. And then you can also use sort of lamoTRIgine valproate or other anti psychotics like you're typing as well. This is quite good um uh anagram for remembering side effects of lithium. There, there's so many side effects and it's really hard to remember them all. So I think this is a good way of um contesting them down. So I remember low thyroid, you can also affect your parathyroid as well. So that's why when you're monitoring lithium, um you need to do TFTs but also check calcium. Um So in the heart, it can cause Epstein's an anomaly, um which is why it's not prescribed to pregnant women. Um and it can also cause E C G changes, um diabetes insipidus. So that explains the thirst and things as well. Um and obviously passing urine more frequently, um unwanted movements, so tremors um and other sort of neuro things like a taxi and confusion. Um So if someone presents to, you know, to a and e for example, and they're on lithium and they have any of these kind of symptoms, then it would be worth doing a lithium level just to make sure that the lithium lithium is within therapeutic range and it's not reached toxicity because it's got quite a narrow uh window for being therapeutic. Brilliant. So, um if everything is okay with that one, we'll move on to the next case. Um So the police bring in a 24 year old man to Royal Edinburgh after he was found acting strangely in a public park, he's been sent, he reports that has been sent to cure the world of evil with the assistance of aliens. He says he knows this because God sent him a message in the form of a cloud in across formation. Um So the trainee the psychiatry trainee decides that he needs to be detained under an emergency detention certificate. So these questions are just about the sort of legal framework in which we work. Um So which is the following is incorrect with regards to an emergency detention certificate, I'll give you a bit of time to answer this one because it's a bit more worthy than the other questions that have been asked before. So the question is which one is incorrect? So that means most of the statements. Yeah, all of the statements but one are correct. So you're looking for the old one night. Okay. Yeah, most people have got this right. So um you don't need uh you don't need a mental health officer to countersign the certificate. So the other ones are true. Um So it lies for detention for up to 72 hours for further assessment. Um You can't appeal it. That's true. You can't appeal it. Um It doesn't give you, it's a detention certificate, not a treatment certificate. So it gives you the right to detain someone but not, not for treatment front. And it's true, the person must be a significant risk to their own health. Um Otherwise you there wouldn't be any legal grounds to do it. This is another important one to remember. So which of these conditions um are excluded from being detained under the mental health Act? Okay. So this one's had a bit more of a mixed response as well. Um So this is another thing I would just remember. I would just recommend committing to memory. Um So to detain someone underneath under the mental health Act, they need to be suffering from at our mental disorder, personality disorder or learning disability. So those are the three criteria that I would recommend committing to memory. But substance abuse on its own isn't um isn't enough. So that's why alcohol dependency um is excluded from the Mental Health Act. Delirium tremens is a little bit different because that's, it's provoked by alcohol by alcohol, but it's um progress to the point of, you know, delusions and hallucinations. Um And on those grounds, you would be able to use the mental health Act but not purely for alcohol dependency. Does that make sense? Fine. No one said anything. So I'll just move on. Um So this next question is just about identifying. Um where does autism fall in those three. Um So it would be, do you mind repeating what type of conditions are under the mental health act? Um So it would be any mental illness, a personality disorder or a learning disability? So I believe autism would fall under a mental illness. Yeah. So I would just commit those two memory, just mental illness, learning disability, personality disorder, but not um I'll call dependency on its own. Yeah, wait, just skipped a question. Um So which the fine? Oh, wait, did I start the pulmonol? Anyways, he says he knows he says, he knows this because God sent him a message in the form of a cloud in across formation. So what's the, the psychiatric description of this term or how would you, how would you define that? Okay. So, um yeah, it's a, it's a delusion in situation. Um A neologism is um a new word that someone makes up. Um So that can happen in schizophrenia as well. Um But a neologism is just something new that they've made up. Um So I'm not sure if it's a, it might, might be a grandiose delusion. Um or you could also just say, uh you know, religious delusion. Um but it's definitely a delusional delusional belief after review the next day by the consultant, um they're converted to a short term detention certificate. So that lasts 28 days rather than three hours. Um And the patient agrees to take an ANZAC Pine. So this is about side effects of antipsychotics. So which um side effect is more likely with the lands a pine than um typical first generation antipsychotics. Yeah, everyone's, well, most people have gone for the correct answer. Um which is diabetes mellitus. So the way I remember it is that um antipsychotics that end in pain. So, OLANZapine, QUEtiapine closet fine. Um I tend to think about them as kind of um like sedation and weight gain. Um They can all cause any of these. Well, the first generation antipsychotics are more likely to cause the extrapyramidal side effects. So, um your acute dystonias, parkinsonism, tardive, dyskinesia, um Akathisia, those are more common with first generation antipsychotics. Um but second generation are more likely to cause the sort of metabolic syndrome picture. Um and a land screen in particular is more likely to cause um diabetes and metabolic syndrome. So, yeah, I remember the Peen's um cause more weight gain. I remember um risperiDONE as um breast parad own. I don't know if that's helpful for anyone else, but that's um more likely to cause gynecomastia than the other anti psychotics. And um the one with the sort of the best side effect profile is our Pit Brazil. Um So those are just a few tips that hopefully um help you remembering all the different side effects because they can, they can all cause all of them really. But um part of dyskinesia is obviously, is more common with the first generation antipsychotics and um metabolic syndrome is more common with the newer ones. Grant. So hypothetically speaking, say he's tried to antipsychotics but they haven't worked. Um And he was started on closet pain. What, what monitoring would be required if he was starting my own clothes? Been oh sorry, someone's just answering the question. Someone said kind of come ask you um risperiDONE, they can all cause it. But I think it's more likely with risperiDONE than the others. Brilliant, everyone's got this right. So weekly fill blood count. Um Why weekly fill blood count. What can it cause that would, that would necessitate that. Mhm. Yeah. Agranulocytosis. Absolutely. So, um that's another thing just to commit to memory. Um, close up in danger of a granular cytosis weekly full blood counts for, I believe it's the 1st 18 weeks of treatment um that you get weekly full blood counts and for another 18 weeks after that, I think you get fortnightly um full blood counts and thereafter I think it's once a month. Um So the risk is um the risk is, is high with has been and um patient should be counseled that if they develop a sore throat, that they should get in contact with um medical practitioners just um in case that's what's happened, but it is a very effective treatment for schizophrenia and particularly in treatment resistant cases. Um You've got more chance of being um sort of hallucination and delusion free on cloZAPine than any of the others. So it is a fantastic premium but not without its side effect. Okay. Um So these are the I C D 10 criteria for schizophrenia. Um So you have at least one of um thought echo insertion, withdrawal or broadcasting, passivity, delusional perceptions. There's third person auditory hallucinations, running commentary, bizarre delusions um or two or more of the following books and it needs to be going on for at least a month. So, um if you saw a patient and this has only been going on for two weeks. At that point, you couldn't say this is schizophrenia, you could say it's a schizophrenia like illness. Um But you can't classify it as such until a month has passed. If that makes sense, is everyone clear on sort of definitions of the terms in the boxes? Um Like the difference between say thought echo and thought broadcasting grant grants, no one said anything. So I'm assuming you're all clear. Um Basically thought echo is when you can hear your own thoughts out. Lied and broadcasting is when you think other people can hear your thoughts. Um And obviously insertion is believing that thoughts are being put into your head withdrawal is that they're being taken out. Um Passivity is that you're under control from someone else. Um And a delusional perception is when you perceive something really in a, in a delusional way. So for example, um I just got a text, therefore, aliens are coming or I just got a text. Therefore, um I'm going to win the lottery. That's a, that's a delusional perception grant. So there's a few more slides about just just the law. Um So I would learn a few things about each of them just to make sure that you can tell the difference between them and know when they can be used. So emergency detention certificate up to 72 hours one doctor's signature can't be appealed. And um you need, it needs to be urgent and you need to be sort of at risk um significantly at risk and impaired in your decision making regarding your treatment and then short term detention is 28 days. Um and you can appeal that at a tribunal. Um And with a C T O that lasts for six months, um consent for a C T O needs to be done at a tribunal. Again, you can appeal it and um you need a signature of two doctors for that. And A C T O can be in place in the community or it can be in hospital, but the treatment will be authorised by, you know, by the, by the tribunal. So, um if they decide that you need to be treated in hospital, then you can appeal it. But until that happens, then you'll be treated in hospital as granted by the tribunal. Uh So these are Schneider's first rank symptoms of schizophrenia. So this isn't currently used um as a way of defining schizophrenia, but it's a good way of remembering the symptoms. Um So, auditory hallucinations, thought, insertion, withdrawal, interruption, delusional perceptions, feelings of being under control. Um These are said to be the sort of strongest indicator um of schizophrenia. So um if you don't think you can get, you know, all the symptoms into your head, then I would recommend learning at least these ones. Um and you'll be able to pick them up in the questions grand. Uh This is a little bit about treatment. So for acute schizophrenia, um, admission to hospital, um, using the Mental Health Act if required, um, for acute behavioral disturbances, um, help Arundel and LORazepam can be used. You might have heard people referring to five and to, um, on your site on your psychiatry placements in hospital. Obviously, before you'd use medication, you need to, you know, speak to the patient and try and resolve things verbally before you go in with, uh, with sedation. Um, or an alternative to hospital admission could be the intensive home treatment team. Um, perhaps and then just the different, um, classes of drugs. So the first generation drugs aren't as commonly used anymore, but you might still see them. Um, and just knowing that those are more likely to. Hello, I wonder if I frozen. Hi, Suzanne, we can hear, but I think your cameras phrasing okay. I might just switch off my camera and see if that's any better grand. I'm sorry about that. So, knowing that the first generation are more likely to cause your extrapyramidal side effect and that second generation are more likely to cause metabolic syndrome. And also knowing that it's a lifelong treatment process and, um, once you're on medication, then you're on it for life. So, antipsychotics are continued for a minimum effective dose. So what that means is the smallest dose that keeps your patient symptom free. Um, and that can be in a, in the form of a depo. So they're slow release and it means that you're not taking tablets every day. But um some medications, for example, Closet Beam doesn't have a depo. Um So that's an oral tablet that you take and you, it's not available in, in depo um formulation. Um And obviously the wider team that's involved. So education about the illness families, um CPN social workers are no teas a role um crucial to the, to the process as well um Of making sure that these patient's can live in the best way that they can good. Um So it's worth knowing about extrapyramidal side effects just because they're easy marks if you, if you recognize it and you know what the treatment is, um it's worth recognizing. So your acute dystonias, that would be things like your torticollis. So neck sort of neck twitching or your eyes rolling into the back of your head. Um and that'll be shortly after commencing treatment. So minutes tires and you treat that with precise leading akathisia is a sort of feeling of inner restlessness. Um And that's, that kind of happens a little bit longer once you've been treated and that can, that can be resolved with per panel. Aw Parkinsonism, obviously, it's, I mean, it kind of mimics um what would happen in Parkinson's disease. So your, your brother can asia your rigidity. Um You're a tremor, but with the tremor that comes from antipsychotics versus Parkinson's, um Parkinson's tends to be more dominant on one side. Um what the tremor tends to be more dominant on one side. Whereas with antipsychotics, it tends to be bilateral and then the tardive dyskinesia, that's sort of the, um, if you've ever seen patient's who've been on antipsychotics for a long period of time and they sort of have this kind of uncontrollable, grimacing and moving their jaw. Um, that's one of the side effects that, um, it's less common to see now because people are on the second generation antipsychotics rather than first generation. But it's also one that has no treatment. Um, so if your patient develops it, then you, you would, wouldn't keep them on that same drug. But, um, you can't really treat the side effect if that makes sense. Grand. Um, so we're just coming up to seven o'clock. So we're, um, halfway through the session at this point. I just want to ask if you'd like a comfort break for a few minutes or if you'd like to press on, um, and finish off the rest of the cases. So there's seven cases in total and we're now on number four. So it's up to you if you'd like to have maybe a few minutes comfort break or if you'd like to just keep going. Grand. Also, I'm sure it's Friday night and people probably have plans after this. Shall we just press on? Um, perfect. So this next one is a six year old man who is a frequent, a tender to a and e and you look at his notes and realize he's had a recent mission for acute pancreatitis and drinks over hundreds of units, 100 units of alcohol per week. On further examination, you notice he has several features suggestive of verticals and careful opathy. So which of the following isn't a feature of Veronica's and capital a calf allopathy can't even say it. I'm getting tongue tied. Yeah. Okay. Most people are going for the right answer. So the features of Veronica's are a taxi, a nystagmus, ophthalmoplegia confusion. Um So there's a good Pneumonic that I've included in the slides later on to remember them. Um But those are the features that would be um part of the clinical picture rather than um it reflects CIA. So, um if you think he's got Veronica's, then you would obviously give paperbacks paperbacks for thiamine replacement to try and prevent course clubs. Um But what other medication would you prescribe for this patient to prevent complications of alcohol with role? Okay. Um So there's a bit of a split here between chlordiazePOXIDE and diazePAM. So they're both um sedatives, but the one that is used for alcohol withdrawal um is Florida's Parkside just because it's a longer acting, sedative, longer acting than diazePAM. Um So Disulfiram that's Antabuse. So that's um to stop someone from drinking, but it doesn't treat them when they're in withdrawal and then help Arundel's obviously an antipsychotic. And um buprenorphine is used as um um opioid replacement. So this is the pneumonic I was talking about and it's coat rack. Um I got it from past meds so I can't be credited with coming up with it, but it just gives you um the symptoms and uh there cause so fervor Nikas, it's confusion, ophthalmoplegia and then I kind of count nystagmus along with that just because it's an eye thing and then a taxi a and obviously thiamine is the treatment and then Korsakov's retrograde amnesia, antegrade, amnesia, confabulation, and course gloves. So that's when I remembered for finals, just coat rack. Um and it's stuck with me. So hopefully it's helpful. So this question is about complications of alcohol withdrawal. So, following withdrawal, when is the peak incidence of delirium tremens? Okay. So this one's a bit of a mixed bag. Um The answer is 72 hours is when the peak incidence of to the room tremin sets in. Um Yeah, so 72 hours. Um I think this is just, it's just going to be sort of route learning really. Um just to get into your head. But also it's kind of reassuring in a way that, you know, if, if someone presents to um quite quickly after their withdrawal, then there's, you know, you've got some time uh to treat them. So they're not going to run into this immediately. It's one of the longer term complications. So, following successful detoxification, he started on midnight. It's therapy. So there's some different medications you can get to try and keep someone off alcohol when they've stopped drinking. Um, so which one is used to reduce cravings? They all have different ways of working but which one is particularly used for cravings? Mhm. Yeah, most people are getting this one. Right. So, the way I remember this is, um, a composite has a C in it and craving starts with the C, so that's how I remember that disulfiram is Antabuse. So that's the one that makes you feel as if you've got a hangover. So if you've, if you've taken disulfiram and then you drink alcohol, it makes you feel hung over. Um So you're less likely to drink more. Um LORazepam is obviously a sedative help, paradores, antipsychotic. Um And naloxone is another one, another option for um training alcohol dependence, but it's not as widely used as um an trapeze and uh can't pursuit and it works slightly differently as well. This next one is about criteria for substance dependence. So which of these isn't um part of the criteria for substance dependence? Okay. This one's had a bit more of a mixed response as well, but the most people have got it right. So, um primacy continuing, despite negative consequences and increasing tolerance, they're all part of the, the substance dependence um criteria, but narrowing of the drinking repertoire isn't, it did used to be, but it's not um it's not in the most recent um in the most recent criteria. So narrowing of the drinking repertoire is, um, where you sort of drink the same amount regardless of, of the day. So, for example, um, someone maybe with a more healthy relationship with alcohol might have, you know, a glass of wine on a Friday and then, you know, they might go out that weekend and have, you know, five or six drinks and then they won't drink again until the following Tuesday and there's not uh a set pattern. Whereas if you've got a narrower repertoire, that means you might have, you know, same kind of alcohol regardless of the day time. Um And there's, there's no sort of fluctuation or change. Primacy means that you're giving, you're giving that importance. So, primacy is that it's the first thought in your mind. Um And it's given importance and supersede it's over anything else. So you're prioritizing, consuming alcohol over other things. Does that make sense? Grant? No worries. So, uh this table has um the criteria, I'm not sure how clear it is to read, but you need to feel a strong sense of desire or compulsion to take the substance. You have to have difficulty controlling substance taking behavior. Um You need to experience some kind of withdrawal when you stop taking it or you continue taking the substance so that you don't have a withdrawal experience, um tolerance so that you obviously need more to have the same effect. Um Primacy. So, um neglecting other pleasures or interests because you're prioritizing drinking or drugs or whatever it is and persistence despite knowledge of harm. So those are the criteria for um substance dependence grant. And then on the right hand side, we've got treatments. So for um detoxification, use benzodiazepines, um thiamine to prevent Veronica's and course clubs and then preventing relapses with either diesel from a composite or um track soon. Okay. Our next case is about memory and I think this is part of at least when I was revising for my exams, I kind of neglected this part because I just thought it would be most intuitive um that I didn't need to, to learn anything about it. But actually, there's a few things in it that um just worth committing to memory because you kind of get used to recognizing the patterns and you find that you can actually um answer a lot of questions quite easily if you've just spent a little bit of time going over all the different kinds of dementia is and how they present. So this case is a 75 year old man. He comes to clinic with his daughter. His family are concerned about his short term memory problems over the past eight months. He's been forgetting things has had episodes of dizziness and needs to be reminded to take his medication. He's behind on his bills which he's forgetting to pay. He has a past history of type two diabetes, hypertension COPD and had a stroke 12 months ago, he continues to smoke. Um his MMSC has 21 out of 30 with abnormal clock drawing. So what's the most likely cause of this man's cognitive decline with that history? Mhm Great. So most people have gone for vascular dementia, which is the correct answer. So, the way of differentiating between answers is your past medical history here. So when you look at this, you think, oh, he's a vascular path. He's got diabetes, he's got had a stroke, he's got high BP, he continues to smoke. So you're seeing a lot of cardiovascular risk factors in the question stem. Uh And that's how you'll differentiate between vascular dementia and other kinds of dementia grand. So if it was Parkinson's disease, there'd be mentioned of um more movement symptoms so erratic in Asia tremor, rigidity with frontotemporal dementia, there might be mention of behavioral changes. Um The patient might be a little bit younger as well. Um With Lewy body dementia, there might be a mention of hallucinations or of sort of fluctuating dementia where they have periods of being lucid and then periods of being um out of it. And then with Alzheimer's, it's that kind of progressive decline over many, many months in a step ways, sort of fashion. This next question is about protective factors. So which of these would be protective against dementia? Yeah, everyone's got that one right. So high level education is protective the way I think about this is just that um the more things you've learned, the harder it is for you to forget everything. That's probably not scientific. But that's um how I've, I thought about it in my head. Okay. I got a couple of questions now about just treatments for different kinds of dementia. So which one of these is not an acetyl cholinesterase inhibitor? Mhm Grant. Um So, memantine isn't an acetyl cholinesterase inhibitor. So, memantine works by um inhibiting glutamate receptors. So it doesn't work on astral choline but the others do. So our patient has vascular dementia. So what is the treatment? What, what you can see in the box? Mhm. Yeah, it's a bit of a trick question. So, none of the above um the treatment for vascular dementia would be to try and prevent further damage. So it's sort of similar to all your stroke and, and my prevention and other cardiovascular risk factors. Um quitting smoking, taking a statin if you need to take a statin um lowering your BP, getting better control of your diabetes. Um living a healthy lifestyle. Those are the things that are going to be more beneficial. And if you were to give acetylcholinesterase inhibitors, for example, um I believe they actually make, make things worse and they certainly don't help with vascular dementia, but they have been shown to be helpful for Alzheimer's okay, which of the following side effect is unlikely with Donepezil. Mhm. This one's a bit split as well, but most people have got it right. So, um constipation is unlikely to be seen within episil. But nausea, diarrhea, anorexia and headache are all more common side effects that you would see with it. So well done. This is another case been yet. So this is a 74 year old lady. She's come with her daughter and she's noticed that her mom is progressively finding it difficult to remember words for common things. She's still independent as otherwise having no issues with her memory. But you find on the mocha she scores particularly poorly on naming and abstraction sections. So what is the most most likely diagnosis based on that? Mhm Okay. So this one has a bit of a split. Actually, the answer here is frontotemporal dementia. Um So the reason it's not Alzheimer's disease is because Alzheimer's would, wouldn't just present with word finding difficulties. Alzheimer's would be more um general memory loss over a longer period of time. Um Whereas this is specific to um two issues with words and naming object. So this is actually a variant of frontotemporal dementia called primary progressive aphasia. Um So there's different kinds of frontal temporal dementia. The one that you most commonly see uh talked about is the behavioral frontal temporal dementia where you know, it'll be a 50 year old man who's personality has changed and all of a sudden he's really aggressive. Um And that's not like how he was before. So that's behavioral frontotemporal dementia, but primary progressive aphasia is um a subset of that and it can present with word finding difficulties like this. So just being aware that it exists, I think is probably enough. So I've got a few little vignettes here of um different kinds of dementia and how you would tell them apart. So older patient age is the most important risk factor, insidious onset, gradual progression. Um And then your amyloid plaques and you're, you're for neurofibrillary tangles, um that's outside much disease and just to have, I think it's a good idea just to have a few things in your brain that you can recall quickly um to be able to differentiate between the different kinds of dementia. So, um also this is more common in women, um which is also worth remembering because women, obviously, women tend to live longer, but they're also more likely to develop Alzheimer's. And then with Lewy body disease is more common in men. Again, age is the biggest risk factor. And usually in the, in the question, you'll see fluctuating cognition. So they might be lucid and then they'll have a period where they don't remember. Um hallucinations uh issues with rem sleep and parkinsonism. So that's how you'll tell that it's Lewy body frontotemporal dementia. So either you're disinhibition, executive function, behavioral changes. Um So that would be the patient I was telling you about earlier with, you know, who's become aggressive, all of a sudden um it's completely different and then it has been disinhibited. That's behavioral frontotemporal dementia. Whereas um the patient that we've just seen um in the question has primary progressive aphasia. So difficult difficulty in language fluency conduction or semantics. This is just a table with the treatments. Um Obviously, at the moment, there's no cure for dementia or um different kinds of memory loss. But there are still cholinesterase inhibitors have shown some improvement with particularly Alzheimer's disease. And um you would think about memantine as a second line option for that if you weren't seeing any improvement with um Donepezil or something along those lines good. Um And then just reinforcing the point that these treatments don't have any role whatsoever in managing vascular dementia that has to be um that treatment is about vascular risk factors. So, stopping smoking, sorting out your diabetes and your BP, um and other addressing other cardiovascular risk factors. Grand. So we're almost done. We've got two cases left. This next one is a 19 year old girl, a woman who tends any with palpitations, she's accompanied by a friend. You notice she's underweight, bradycardic and hypertensive. Her E C G show signs of hypoglycemia. Her friend admits the patient has issues with food, regularly, weighs herself and has experimented with laxatives to help with weight loss. So which of the following is not a short term risk factor and patient's with anorexia, nervosa. Mhm Most people are getting this Right. So, osteoporosis is a complication um with anorexia nervosa, but it's not a short term risk. Um osteo process is something that will develop over a longer period of time. So the other things mentioned, like you're neutropenic sepsis, arrhythmias collapse and Briefing Syndrome, they're short term risks. Uh So I think I've got the question. I've written the question twice. Oh, no, I haven't. Never mind. I thought I'd put the same question in twice but I haven't. So which of the following is not a recognized feature of anorexia? Nervosa? Mhm Okay. So this one's been, the results have been a little bit more mixed with this one. But yeah, Luke Cortisol um is not a feature of anorexia. So with anorexia, you'll see low FSH and low, that should say low LH and FSH because you're in a state of um hunger. So your body is thinking I'm not in a position where I could have Children here. I'm not in a position where I can ovulate. So you regress to your sort of pre pre pubertal hormones. So you're gonna add a trophies are low grant um Growth hormone is high. Um cholesterol is high and cortisol is also high. Um So the way I remember this is everything is low except geez and sees, so growth hormone cholesterol, cortisol, they increase. Um So jeez and sees increase and everything else goes low fine. Um So this slide is just differentiating between the different eating disorders. So anna anorexia, nervosa, you need to have B M I of under 18.5 or a weight of 15% less than expected. Um, self induced weight loss. So that can be a restriction or binging and purging. So the method doesn't really matter. Just it's, it's more to do with the effect. So, um I think people sometimes often conceptualize anorexia as someone who's not eating but it could be, you know, they could be eating, but they could just be taking, they could be taking laxatives to combat that or they could be over exercising, for example, um as well. Um common to eating disorders is the overvalued idea about body image, target weight fatness. Um And then with anorexia, in particular, there needs to be an endocrine disturbance. So, um in Children that could be delayed puberty, um in uh in female patient's who've gone through, um you've gone through puberty that their periods could stop. Um And then in, in, in men that can present with sort of um oh and women as well, obviously, um decreased libido and then increased cortisol and growth hormone grant. Um With bulimia, nervosa patient's can have a normal uh normal or typical average body weight or they could have um they could be clinically overweight. And believe me, Nervosa tends to be the the binge eating and purging again. There'll be an overvalued idea. Um and some method to contact contract weight game. Um But in the long term, the complications aren't as high as they are for anorexia. Nervosa anorexia is actually the deadliest mental illness. Um, you over any other mental illness? It has the highest um highest rate of death. Um And I think there's been a lot of discussion about um the way it's diagnosed and when people are considered in quotation marks, you know, sick enough to be given that diagnosis. So I think that there is discussion about um whether it should be, you know, whether you should wait until patient's have a B M I, that's so low to, to address it or whether you should be a bit more proactive earlier on in the, in the illness course. Um but that's still sort of being discussed about and debated. Okay. Um We have one final case and a couple of Ragtag questions at the end and then um if anyone has any other questions, I'll be happy to, to answer them then. So our last case is a 14 year old girl, Sarah. She's struggling at school. She's significantly distressed about her ability to do well in exams and she's played by insecurities and worries about her appearance. These feelings are present more days than not and she requires constant reassurance from her parents and teachers. She started having trouble, trouble sleeping and concentrating, it's affecting her social life and she no longer hangs out with her friends like she used to. What do you think is the most likely disorder that's going on here. I'll just go back to the case so that you can see, you can see that as well. Mhm. Okay. Everyone's, everyone's got this right. So this is generalized anxiety. So it's not depression because it doesn't mention anything to do with low mood anhedonia or fatigue. Um It's not panic because it's not mentioning discrete panic attacks. It's a general constant, more or less constant state of anxiety that's been there for quite some time. So that's why it's not panic, separation anxiety um is something that presents in childhood and it just basically means that um you're anxious when you're away from your primary caregiver. So that's usually something that happens with, with younger Children rather than someone who's in their teens. Um And social phobia again, it doesn't really sound like a social phobia. Oh, sorry. I don't understand. Um Someone said done anyway. Um which of the following is most likely to present only after the age of 10. So I think the purpose of this question is to understand um sort of neuro neuro developmental disorders versus um things that develop later on in life. Mhm So most people are getting this right. Um It's bipolar. So bipolar tends to only present. Um after the age of 10 grant, Sarah's mother is very concerned that she has anxiety and it could develop into depression, which the following is not indicated in the management of depression in young people So this is something that's worth getting into your head. The difference between the treatment between with um adults and Children when they're depressed, just cause it's relevant both to pediatrics and psychiatry. Mhm. Okay. So most people have got this right. So when you're managing depression in young people, CBT supportive therapy guide itself help. They're all sort of pillars of treatment that everyone would get. Um but when it comes to management with um medication FLUoxetine is the antidepressant of choice rather than paroxitine. Um So the way I remember this is um a picture, I remember loads and loads of kids getting colds and flues. Um And then I think of FLUoxetine. So I'm not sure if that would be helpful to anyone else, but that's one of the ways I remembered it. Yeah. So the answer here is um paroxitine is not um not indicated in the management of depression for Children. And it's important to remember that antidepressants shouldn't be offered to Children or young people except in combination with some kind of psychological therapy at the same time. So you, you shouldn't be prescribing, you know, FLUoxetine on its own. It would only be given in the context of either CBT or another kind of uh psychological support grant. So those are all the cases. Um We've just got a few. Oh, sorry. I meant to send it in a different tab. No worries. That's grand. No worries. Um We've got a few more questions and um, then I'll open up for further, um, any last minute questions before we head on. But hopefully, um, it's only half past seven night and we have until eight o'clock. So if we get finished and there's no further questions, then you'll be able to head on a bit earlier. So this first question is an 82 year old lady with macular degeneration. She's brought in by her GP, brought into her GP by her daughter who's concerned that she's been asking where the cut is, why there's cows grazing in her garden. What's the most likely diagnosis here? So most people are going for Charles Burnett. Um And you're exactly right. The clue with this one is that there's a history of some kind of vision problem. So, Charles Burnett syndrome is basically where your brain kind of tricks itself, whether you, where you've got problems with your sight and your brain kind of fills in the blanks um with other things. So people will have, um they might see things that aren't there, but it's because their, their brain is filling in the gap that their eyes um have left. So in the question, if the, if the question is alluding to Charles Burnett, there'll always be some information about a site problem. So it might be macular degeneration, it might be cataracts, it might be glaucoma um because it's associated with a lot of other um ophthalmology conditions, but that's how, you know, that it will be Charles Burnett and not something else that there'll be, there'll be a reference to some kind of problem with the Eyes Grant, which SSRI is considered safest to use after an M I, we'll just start the goal. Mhm. So most people have got this one right. Um sertraline is the safest, the safest one to use post M I and for unstable Angina as well. Um, so even, I mean, even if you didn't know the answer, I would say, Sir Julian is probably a safe guess. Um just because it tends to be first line, it tends to be the one that's prescribed most often. So if you think about just the average patient in the community, um they'll probably have had something in their past medical history. Um and certainly is the most commonly prescribed one. So even if you didn't know the answer, that's kind of how you could go about working it out. And then the last question I have is which SSRI has a particularly high risk of discontinuation syndrome. Mhm. So similar. There's a split in this one, but I think that the correct answer has just about just about got more responses. Um So, Paroxitine has the highest risk of discontinuation syndrome. Um FLUoxetine has the lowest. So I think that's probably why that's the one that's given to Children, but Paroxitine has the highest risk of discontinuation syndrome. Well done. Thanks everyone for sticking with me. So that those are all the questions I had for you. Um The link for feedback has just been put into the chat, but at this time, I'm very happy to take any other questions if anyone has any. Thank you very much Suzanne for this session. Um You're probably sick of hearing me say this one out, but please do feel like the feedback form in the chat. You can feel free to stay behind if you have any questions for Suzanne. Otherwise, thank you for joining us for the past week and I wish you all the best for your exams. Yeah. Good luck for your exams. I'm sure you'll do really well. You're welcome. Also. Feel free to log out if you don't have any questions. Enjoy your weekend. Um, Suzanne, if there aren't any question from the audience, you can feel free to leave as well. Um, once again, thanks so much for coming on as a tutor. Yeah. No worries all the best for your exams. Thank you. Bye bye.