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Okay. So hopefully now everyone can see my screen. If there's any problems, then please do. Yeah. Uh Thank you chat. As I was saying, as Emily's put in the chat as well. If you do have any questions throughout, please do, let me know that's going to be the much easier way of me working out then talking about the right stuff and covering all of the important things that you'd like to cover. Um I might get started if that's all right. It looks like we've got a sort of a very large group of students here. So it's lovely to um welcome everyone. We'll just move the chat out of the way so I can see what I'm doing and yes, I'll try and keep an eye on things that Emily as well if you can help, make sure if there's any questions I'm ignoring. That would be lovely. Thank you very much everyone. So, as a starting off an introduction. So I'm Doctor Michaela Henson, Raven, I'm a fellow in Medical Education in East London Foundation Trust uh in London. Uh and I'm an ST five, the higher trainee in general Adult Psychiatry. This is a talk that I'm used to giving to medical students in London. Uh If there are bits that would be more relevant or less relevant for you, then please do, let me know this is going to be a bit of an overview really about what the mental state examination is. Um why it's important in general medicine and particularly in psychiatry, what the component parts are. So as you're asking on it about how practically you do it, we'll talk a bit about those questions will see them eclipse as well. That will hopefully give a demonstration of how it works in practice. And then how to apply it in clinical practice is of course the most important thing. So how we use the mental state examination? It's a very brief bit on what the state examination is. It's not the MMSC which is a confusingly described thing. I think this is something that's common in all. Yeah, use different exams. But again, apologies if this is more of an English centric um confusion so that the mini mental state exam is a test of memory. This is similar to the marker or various different um sort of 30 point tests of memory, cognition, orientation that take place um in more older adults settings, the mental state examination is not that despite having a very similar name, it's a standardized structure, it's our psychiatric examination tool and it's used to describe how someone appears, how someone is presenting at the point in time when you are seeing them, it enables us in psychiatry to present our findings on examination. That means that we have structured ways describing how someone's oncology and presentation. It's not diagnostic or predictive. It's just like any other examination in a physical health setting. For instance, it doesn't tell you precisely what's going on. It doesn't give you a clear diagnosis just from the examination, but it helps you to describe in a snapshot at that time about how someone is presenting, how they appear. And that gives you a lot of clues about what types of disorders, psychiatric disorders or otherwise might be going on. Um So I hope that makes sense is a very brief outline of what we'll be looking at today. Usually when I give this lecture, it's either in person or with a relatively smaller group. But I think we can still use the chat if people would be willing to um put any answers in and share their thoughts. Why might the mental state be important? Why is it something that we're dedicating? It's a two slots lecture to today. What might the limitations be and how might it be relevant to the wider medical context? What's, what's the purpose of it or what's the use of the mental state examination outside of just being in general psychiatry? Is it something that people think they might use or that they might find helpful when working in other specialties other than psychiatry people are able to have, I think two themselves. Uh, and if you're able to type in the chat, that would be really lovely. If you have any thoughts about what might be answers to any of these questions be, or what you might think there's no right or romances as, um, just whatever you, you would like to share. Oh. And I'll see if my camera works with my internet connection. That might make things a little easier. But that's all right. If no one wants to or is able to, to share any thoughts on this, I guess it's a little bit of a leading question as well. Oh, perfect. We've got a few answers. Perfect. Thank you, Ruben. And, well, so it's important because it assesses different aspects, the memory and cognition, like I was saying, it does come into that aspect a little. Um, so cognition is part of the mental state examination, but it's not the main focus. It's not like one of those memory assessments that we do is separate exams. Um, it's more looking at the different types of presentations psychiatrically that someone might have. Um, thank you. That's, yeah, exactly. Right. It makes the differential diagnosis easier. That's the aim. It's, it's an examination just like a cardiac exam for instants. Um, it's a way of being able to describe exactly as you said. Um, on the Dalai, it provides a universal template to make interpretation of someone's presentation easier for other doctors, it's how we communicate and how we share our psychiatric findings. Psychiatry is often quite subjective, it's quite um observer dependent. So what I see as someone's psychiatric presentation, how I might interpret what someone is presenting with could be very different from another psychiatrist. But by having as structured uh setting as possible, it makes it much easier to be able to try and get things as objective as possible. We don't have blood tests or sort of easy brain scans in psychiatry that will tell us a straightforward diagnosis. So we have to try and make it as objective as possible. And thank you. I mean, you said, yeah, and that's exactly what I just said. Perfect and psychiatry observation is very important. The differential. Um Yeah, not just complaints. So really important to go with how someone is presenting and we'll look at that. It's how someone says something, not just what they say that's really important for us to be able to tell what the differential diagnosis might be and to have hints about what might be going on for the person we've hinted. There are a few of the limitations as well. I don't know if anyone has any thoughts they want to share as well cause there's always things that I forget that could be included as the limitation for the mental state examination. I mean, one thing that we've mentioned already is it's a snapshot in time. It's only really when you can comment on is how someone is presenting at that moment when you're interacting with them and in different mental health conditions, people's presentation can vary an awful lot. There can be a big fluctuations in how someone can be presenting. That was exactly another problem as well. Um Ed Plaza, it depends on the examiner because as we've said in psychiatry were really subjective and there's no objective, blood tests or measurements. It does rely on um the observer being able to interpret accurately as best as possible and to try and fit what they see into that structured framework. Um Cultural differences are a huge, huge important limitation and it's really important to be aware that what we're seeing in the mental state and how we interpret someone's appearance or behavior or what they say or how they say it is very dependent on their cultural context and what is appropriate or not appropriate for their background. And I'll, I've got a few good examples of how that's come into my practice. Um That's a really important thing to be aware of and very difficult to really fully understand someone else's cultural context, which is partly why psychiatry we rely so much on collateral history as well. We don't just go on what the patient is presenting to us there and then we have to take this all in context. Um And I guess that's another big limitation for the mental state examination. It doesn't cover all of those points of a psychiatric history or of a collateral history where we would speak to someone's family and friends to find out what else is going on and how that fits with their cultural context. And that's really important to be able to come up with any conclusions about what might be going on for the person. And then the last point very briefly because I don't want to run up time to talk about other interesting things. How is this relevant to the wider medical context? Do we think that the mental state examination is just something that is important for me as a psychiatrist? Or might it be important for people in different medical specialties? A bit of a leading question because as I said, we're spending two hours on this, this morning clearly, I think it's important. But the question I guess is whether I'm just biased as a psychiatrist or is there actually a wider relevance? Perfect. Yeah. So we've got a couple of replies thinking about organic causes and that's a really important. Um Yep, CVS is strokes as well. So there's a lot of physical health concerns that could present, could appear as though someone has a psychiatric concern and being able to accurately discuss and describe psychiatric presentation is really important to then be able to help just doing fish between those different presentations as well. Exactly as you said as well. Alliot um mental health problems can also lead to physical health problems. Uh brilliant answers here, it could improve the communication as well between patient and position and actually just having an awareness of how someone is presenting how they're coming across is quite important in a number of different contexts. In terms of how we communicate appropriately with people, an awareness of what their behavior is like while we're interacting with them, you could argue is actually just part of communication skills for doctors. It doesn't have to come as part of a sort of psychiatric set of examination questions. Um And of course, yes, the diagnosis and degree of disease is a really important one too. Thank you so much, everyone for share ing all of your thoughts. That's really lovely to have interaction even via um cat. Thank you very much. Just to those of you who might have joined a bit later as well, just to reiterate if there's anything that I say that doesn't make sense or if you have any questions, please do put things in the chat. I'm able to see it reasonably well at the minute. So we'll see how well I'm able to multitask and Emily is the moderator, very kindly be able to help with those things that I miss as well. Um But do just make sure that you're saying if there's anything that doesn't make sense or that you want me to cover as well and I'll do my best. Okay. So let's move on. This will not me. There we go. So we've covered a lot of what we've said here. So my thoughts for why the mental state examination is important, as I said, it's just like our examination tool in other medical specialties. It like with a cardiologist would do a cardiac exam, a respiratory physician would do a respiratory exam. It's our standardized way of examining patient's and it's useful to be able to describe the presentation at any given time that has limitations because it's time specific and things do change. It's subjective as we said, and it's reliant on the examiner and their skills at eliciting symptoms, but also of uh sort of documenting them and fitting them into the structure in an appropriate way. And it does require the cooperation of the patient to assess fully. Although as well see, and as you can reflect and think about, there's an awful lot of information that you can get from someone without them answering all of the questions that you ask. It's possible to actually have quite a lot of information about how someone is presenting without all of those things too. And the fact that it's time specific can also be an advantage because it means that you can compare house on is presenting at a specific time to how their baseline was or how they were presenting when they were. Well. So for instance, if I see someone in A and E I will look back and see what their presentation was like when they last saw their community team three months ago, so that you can really get measure of change. What is going on for this person is how they're presenting now different from how they usually present. And that helps to eliminate some of these cultural or differences that we just don't know whether someone's usually as they present, that personalities are very different as well. And that's an important thing that psychiatrists often get criticized for is sort of pathologize ing or making uh illness where it doesn't exist. And that's a really important way of making sure that we what sort of mitigate against that by comparing to what someone's baseline is like. So that's all my thoughts of limitations down bab and then a brief thought about why it's important in medicine. I'm just going to turn my video off to stop it from getting distracted because I think my hand and that's struggling a little. There we go. So as a very brief detail that in medicine, there's often a dichotomy of this artificial division between the mind and the body and it doesn't really exist uh as far as we know, there's very artificial separation. But actually, as we've already talked about, there's huge overlap between the mind and the body. And it's impossible to just describe something as psychiatric with justice organic that actually there is an awful lot of control that the mind has over the body and vice versa. So everyone knows that feeling of when you are nervous in school or if you have an exam coming up, sometimes your stomach will be rumbling. You perhaps have some indigestion. You might have some loose stools and diarrhea. That is a complete uh everyday interaction between the mind and body that everyone recognizes this idea, that they're totally separate is very old fashioned and hopefully one that's changing as well. And as we've said that there's all sorts of different reasons why being able to assess someone psychiatrically can be useful from a physical health point of view. So we know that people can have of course, mental health problems and coexisting physical health problems. Sometimes people's mental health contributes to their physical ill health. So a lot of the medication that we prescribe as psychiatrists increases people's risk for instances, the moment mentioning of strokes or heart attacks, we also know that physical ill health can contribute to mental ill health or sleep stress, any kind of stress of pressure on the body is something that is a well known trigger for people developing mental health problems. And then finally, as we've mentioned as well, people with physical ill health can present with signs or symptoms of mental illness as well. So the classic example that often talk about that comes up in um exam questions is thyroid. If someone has hyperthyroidism, it's in excessive for production, they thyroxin, they can look as though they're manic, they could or very anxious, they could be losing weight, could be jittering. It could be really on edge. The counselor to that is that someone with hypothyroidism can look very much as they're, they're depressed that they can uh be putting on weight, have no energy, have very low mood, be tired all the time. A lot of the symptoms of depression, but actually, it's a purely physical health problem that can be easily reversed by giving blocking viral load production. So just a couple of examples of that overlap there, I often say as well. One of my examples of why it's useful for general medical doctors to be able to describe psychiatric presentations. I was very first placement as a medical student, I was on a renal transplant ward and I saw someone who had previously been fit and well, she had a renal transplant. And then as a result of the combination of medications that she was on an immuno suppressants and steroids, she developed mania. I had no idea as a brand new medical student, what was going on. All I knew was that when she, I turned up, you know, at the beginning of the week and she was perfectly pleasant and happy to talk to me and I was able to have a sort of usual conversation with her. But then by the end of the week, suddenly she was totally different, she wouldn't stop talking. She had these very odd ideas that she didn't talk to us about before at all. Something was totally different with how she was and I didn't have the words at that time to be able to describe what was different about how she was presenting. She was just very odd and things were all over the place. But if I had recognized and if I had those words to be able to understand how she was presenting for one thing, it would have helped me to understand what she might have been developing that it was a mania as a result of the steroids that she was on, which is not uncommon. Unfortunately, in physical health hospitals, we see that sometimes but also it would have helped the, if the medical team didn't have the words to be able to describe what was going on for her, it would have delayed her access to treatment and her engagement with psychiatry. So I think there's a few different examples of why things could be really important to be able to accurately describe someone's mental status, psychiatric presentation even for physical health reasons. So after all of that preamble, let's move on to the component parts. So different sections for the mental state examination. So we want to think about what someone's appearance is, how they're behaving what their speech is, like, what their mood and affect. And we'll talk about the difference between those elliptically of English language orientation for the the niche differences there between mood and effect. But we'll touch on that briefly anyway, we'll talk about abnormalities of thought. So we'll look at thought form, thought content and thought flow, perceptual abnormalities, cognition does come into the mental state very briefly at the end as well. But as of saying, it's not the primary focus and insight, which is a really important part. And one thing as well that it's important to have at the back of your mind when you're thinking about the mental state is how does interacting with this person make me feel? And that sort of counter transference, the emotions brought up in us by our patient's is a really useful way of being able to think about what might be going on for the patient as well. So that's a useful thing to reflect on there too. Okay. So we'll move on briefly and I'm aware of times I don't want to spend too long. But if people are able to, if they feel comfortable, I wonder if you might be able to type in how you might describe this man to someone who can't see him. So say, for instance, you have a friend who can't see your computer screen, how might you describe what this person looks like? What this man, how this man appears? And this is another example of sort of how you me asking you to, to think about this is thinking about what we're able to tell just from someone's appearance and behavior from a picture without interacting with them. Great. So we've got a lot of descriptions that we've got depressed, distressed, sad distraught, stressed, I wonder. Perfect. So we've got a couple more. So I wonder if we could stick with, how would we, if we're thinking about trying to do this as objective and as um as specific as possible, how physically would we describe that this man is sitting? So we think he looks depressed and I would agree. He does look as though he is not happy. Perfect. So we've got a couple of more physical description. So he's hunched over. He's, um, someone said underweight as well. And I think you could argue that it looks as though his trousers are sitting quite loose on him. He's slouching in his chair. He's elderly, perfect. His hair isn't tidy. Perfect. Yep. Again, a lot of people are thinking more about this in a, we're putting a value judgment on what we can see. So I completely agree. He does look as though he's overwhelmed. But the important thing before we go to that is to put it all together. So why does he look like that to us? Why does he look as though? He's sad. And exactly. People have got this that he's hunched over. He's got his hands in fists, doesn't he? His clothes? I agree. Look as though they're quite messy probably, but he's, he's hunched over, he's got his elbows resting on his legs and he's leaning, he's not making any eye contact. He's got his fists covering his hands. And the fact that he's got his hands in fists really does. Look, it conveys quite a lot of distress to us. And that's the important point I was trying to, to make with this picture is that I completely agree that you would describe this man. If you had to say whether he was happy or sad, you would say he looks sad. He's distressed in this picture. But the important thing rather than jumping straight to the emotion is what about his appearance? And what about his behavior makes us think that and that's the really important step because if it's a little bit like in um mathematics lessons when I was at school, we were always told that you have to show your working because if you just go straight to the answer, then people can't tell why that might be. And so for this gentleman, let me see if I can click. So here's my rough description. So I've said that he has an older, appears to be a white Caucasian man. He's got gray hair, he's balding. Other people who have commented on that as well as I've missed that off my description and he's wearing blue jumper and Frau Zer. Zer. I would agree that they look like they don't fit very well. So perhaps he's lost some weight. Um They look quite dirty perhaps and his shoes, I think we could say you're quite dirty. Perhaps to, he's hunched over, his elbows are resting on his legs, his hands are bunched into fists, he's covering his eyes and he's not making eye contact. And so from that, because this is how we've described him, I would definitely agree that we would say that he's sad rather than appearing happy. And he would even be able to say, I think, yeah, he looks as though he's distressed, overwhelmed all of those emotional words that we've used to describe him as well. But it's important to show you're working. And that's kind of the um one of the first principles really of the mental state examination is that it's not jumping to what we think the diagnosis is or what we think the emotions behind any of what's going on is we're showing are working for why we think that he uh is in this emotional state. What is it about his appearance and behavior that makes us think that he is sad and that's all of those things that we've covered there. So I hope that makes a bit of sense. These are the types of things that we would want to comment on when commenting on someone's appearance and behavior. So it's useful to be able to describe what someone's rough age, gender ethnicity is what their physical appearance is. Um their clothing, is it appropriate for the weather or for the context? Is it inappropriate? So I've seen patient's in any, in the middle of winter in England where it's cold who have been wearing a very, very short sundress and no shoes for instants. And that's very inappropriate. Not just for a healthcare context, but for the time of year, that's not what you would expect someone to be wearing and that's not what is in keeping the sort of cultural norms and appropriateness for the situation and for the setting. what's their self care like? Are there any signs of neglect? Do they look as they, they're able to look after themselves or do they look as though they haven't actually washed for a while? And I guess anything really is a bit of a battle for the end here in terms of appearance, anything that's unusual, odd or striking about their appearance. Is there anything that makes you do a double take or think that this is outside of what we would usually expect? Um, again, uh uh an example, I saw someone in a any and she was dressed extremely flamboyantly. So she was wearing very, very bright colors. She had a tea cozy on her head as a hat. She had neon leggings, uh I think three different jumpers, um, and particularly bright and boldly colored makeup. So she had like very light blue eyeliner and lipstick, very badly done all over her face. It was smeared and she was, I think in her late sixties and had a diagnosis of bipolar effective disorder. But from the on initial appearance, it looked as though she was very unwell. This is a very, very odd presentation and she looked very odd, but actually looking back at her notes, it was apparent that this was her usual way of dressing that she was an interesting flamboyant over the top character. And this was her personality. She liked wearing bright colors. She liked wearing odd things as hats. But the thing that was apparent from her mental state examinations when I looked back through her notes from her community team was that when she was well and stable, her makeup was always perfectly done. She didn't have lipstick sort of all over her cheeks or her teeth and she would always take great care in her appearance even though she wore very outrageous clothing. And so the outrageous clothing wasn't inappropriate for her baseline. That was usual for her to where, what on if you saw someone walking down the street, you would think that looked very odd. But actually the change and the important difference that I was able to look at from the comparison with the notes was that her self care and her makeup was done very differently and she was presenting with the rest of her mental state examination findings as well. We're clearly that she was not well and she was really struggling with her mental health at that point. But thinking about someone's baseline is a really important there as well, thinking about behavior. So we look at the report. Are you able to engage someone in a two way conversation where you're able to get them onside? You can get them to open up and to talk about how they're feeling in a usual interaction with someone who didn't have any mental health problems. You're able to establish a good two way dialogue and a good report that might not be possible or it might be that people are over familiar with their um, communication with you with different mental health problems as well. What's the body language like? How are they sitting in the chair? Are they sitting down or are they pacing up and down the room? Are they very agitated? Very distressed? What's their posture like? Are they sort of sitting hunched over in the chair as we saw with that picture or do they have other mannerisms, any ticks, for instance, that you can see in organic and nonorganic psychiatric health problems too? And this idea of psychomotor retardation or agitation is whether someone's movements are slowed down retardation or speeded up agitation. So that's again, typical if someone is very severely depressed or has a catatonic picture with schizophrenia, for instance, you might see that their movements are very slowed down and sometimes people can talk about it's like they're moving through treacle, they can hardly move the limbs even. Um, or if someone is perhaps manic or very distressed, they might be agitated, they might be moving all over the place, their hands might be moving all over the place, important to nose, any differences or changes in behavior there that we see. So, moving swiftly on, I hope that will make sense for appearance and behavior we'll go through systematically and we'll think about speech and a lot of this is perhaps a little bit more obvious about what we look for in speech. So we think about the rate that someone is speaking at how quickly, if again, someone is very depressed, they might be speaking more slowly if they're quite agitated or animated, perhaps manic or again, perhaps, um any other form of agitation, they might be speaking bit more quickly, um difficult to interrupt. Perfect. Thank you, Miriam. As well as the seen, you said, the amount of speech is another really important one as well. So, uh let's move on to the other ones that we have on my list too. Volume is very obvious. When are they speaking loudly or quietly um own? And this is a hard one really to think about sometimes. But if you speak with a monotone, it sounds very odd and I don't know if it's coming across on the TV, the video call at all, but when you speak with just one tone, then it's very difficult to hear. And I find it quite hard to impersonate because it's very different from how I would usually can speak as Well, so there's different ways that people can speak. And the idea of having um uh monotone uh communication is often something that you would see more in, again, perhaps someone with a depressed episode or perhaps with some forms of psychosis as well. But the usual wave conversation to happen is that it flows naturally. There's a natural rhythm to speech and that as you can hear from my speech, often we go up at the end of sentences or you go down in tone and that natural, up and down in tone is just to what we'd expect at the monotone descriptions that sound very different uh flow or rhythm of the conversation as well. And fluidity, this is the other thing that you were mentioning Mirim as well. Um And thank you as well. Someone else has said the fluency and rhythm too. So is the speech fluent? Are they able to speak without lots of pauses or hesitation at odd points and conversation? There are some points when I'm pausing what I'm saying, just to make sure that what I'm saying, make sense and I'm coherent in my speech. But if I were just off the random points in a sentence, it feels very different. And that is a very odd flow or rhythm of the conversation and there's no fluidity as well. There people have these other difficulties with fluidity with different organic health problems. So word finding difficulties, which is Sadio disaster as well. We often see does someone have a CBO or a stroke and a stutter or a stammer can be very common in different individuals. But again, it's often a useful indicator if someone has a worse stammer, that can often be a sign of more stress for instances. It's useful to note if that is present and we'll talk a little bit more about these clang associations and punning when we come to the video section as well, because these are um having said that the findings that we have on mental state examination are not diagnostic. There are certain terms that we use that fits specifically with certain diagnoses. So it's a little bit like in uh cardiology examination. If you see splintered hemorrhages or you say you see splintered hemorrhages in someone's fingernail, that means that they have endo colitis. But the saying one means the other if that makes sense. So, neologism is something that is very classically seen and it's a typical description of what someone would present within mania where someone makes up new words is what neologism means. And planning is something again that seem very commonly in mania. But we'll see that in one of our video clips to like moving on, moving on, we'll think about the mood. So hopefully, that will make sense with speech. I would just think about major, I'll keep an eye on time. That would be good to um just uh keep an eye on the time and make sure that we can have a little bit of a break at some point as well. So perhaps after the next um video capability. So perfect. Thank you, madame, you commented as well. But mood can be subjective or objective and there's often a bit of a confusion about this means in terms of mood or affect and then what subject of an objective means within that. So I am quite a visual person and I like pictures and I like being able to sort of imagine things. So we think in psychiatry about mood and this concept of affect and this is something that can be compared to climate or general weather or the day to day weather. So we could think about this in that if we, I can click perfect. So if we think about the season, so we have winter, spring, summer, that's the general prevailing weather. See, we would expect in England, we would expect winter to be colder and summer to be hotter. But that doesn't mean that you can't have cloudy days and rainy days in summer. This is how we think a little bit about the difference between mood and affect. Mood is sort of the prevailing weather conditions is what we would expect things to be like on a general picture for people. But affect is how someone is on a day to day basis is how things are there. And then for that person, the other important things that we have as well is thinking about how mood is subjective or objective. So subjective just means that's how the person themselves describes mood. Objective is how we see that person's mood. And this is very difficult because we're not objective as we've mentioned that all of what we think in psychiatry is completely dependent on our own perceptions. And we're not some sort of grand high arbiter of someone's mood, all we can say is how someone appears to us. And so that's generally the terminology I prefer is what someone describes themselves, what the patient self reports and what it appears to me rather than objectively because I'm not a particularly objective affect, uh an objective observer. Perfect Lena, thank you. So affect is time specific based on when we interview the patient precisely. So it gets a little messy when we think about affect, but it's really is the variations that we see there. And then so it's not what the overall whether is, it's whether it's currently windy or currently rainy, it's the variability. And so this is one of the easier ways I find apologies. Again, if this doesn't make so much sense. But again, like thinking about pictures, so there's different ways that we describe someone's affect. So we could think about them being reactive, that they would be able to respond appropriately to ups and downs and conversations. So if we spoke about something sad, they would be appropriate and sad in response to that. If we spoke about something happy, they might smile and be appropriately happy in response to that too. It's a little bit like if you throw a pebble into a lake, you would expect to see a few ripples. You wouldn't expect for the middle picture. If you through a pebble into a lake, you wouldn't expect it to remain completely flat. That's point odd. You, you would expect within the normal range of conversation, of different topics that there would be some kind of emotional range and variation. So this would be described as flat or blunted affect. You throw a pebble into the lake, you talk about something emotional, either happy or sad, but there's no ripples. And then the far right is a label effect. So if someone is um very, very up and down in their emotions, so you might not even throw a pebble into the lake. But then suddenly there's like these huge waves going on in the lake. This would be when someone is very label, very, very up and down. Uh that one minute, they might be crying one minute, they might be laughing and it's often got nothing to do with what the topics are, are being discussed. It's just uh emotions are very, very up and down. So I hope that makes a little sense. There's often it's a very artificial distinction between mood and affect and how we describe variability. Um So yeah, mood swings would be one way of seeing it so far. But it's more in terms of how we see the person. So people might describe themselves as having mood swings. But actually, when you're talking to them in the conversation, their mood might not change, their emotional state may not appear to go up and down, particularly. Um So people will describe themselves as having low mood or food mood. Often, I'll just use someone's direct quote. So if I ask someone how they're feeling ill, say uh yeah, I'm feeling fine. So they might say they're feeling fine, but actually they're not making any eye contact. They look perhaps a little bit like that man. In the very first image we saw maybe hunched over, they might look to me to be very sad. And so then I would say that they're subject of description is quote fine because they've described themselves as feeling fine. Sorry. I think I might have got kicked out briefly for a minute there. Can you hear me? Okay. Yep. Perfect. Thank you. Okay. Well, go back to sharing there. We can. Hopefully that's all right. Perfect. OK. I'm not sure what happened. I just decided to stop me staring. Uh I hope that makes sense. So that's how I would document someone's mood and affect in notes. So I would describe if they said for instance, they're subjective mood was fine, but they appeared to be very low and they had very flat affect. They weren't really, they weren't crying, they just looked very cut off, blunted any kind of response. There wasn't any weather going on. If that makes sense, the no wind, no rain, it was just shut down. I would describe that as being subjective mood, quote, fine because that's their own words, objectively low mood with flat affect and I hope that makes sense, but it does take a lot of descript practice too sort of describe more accurately. So, thank you up. You said how to differentiate between label and reactive. So reactive is really a lot of what we think about in psychiatry. Is, is this appropriate or not? So if for instance, I'm speaking to someone from an hour and at the beginning of the conversation, we're talking about something happy that happened for them that day and uh something goods that went well for them, they would smile appropriately about that if later on in the conversation, say half an hour in, we're talking about something traumatic that happened to them in their life and they become a little tearful. Perhaps when thinking about that traumatic event, I would say that's completely appropriate because their emotional response is varying, but it's varying with topic, it's varying appropriately with topic and it's not happening so quickly or out of context for the conversation. So that would be my difference between reactive and label. But you can see how a lot of this is very culturally dependent and on my perception because my uh emotional response maybe far lower or far reduced than my patient's, for instance, or the other way around. And so I might think actually that their emotional response is really disproportionate and they're completely overreacting and far more emotionally label than is appropriate. Whereas that might be totally in keeping either for their personality or for their cultural or um you know, uh family background and context. So it's important to take all of this with a pinch of salt and to try and think about how we can document this as objectively as possible. Um And how much as far as possible, we can keep things within patient's cultural context specifically. But I hope that makes sense. I think I've done enough talking for a little bit. Oh, no. First of all, we'll think about this. So this was another important topic again, thinking about appropriateness. So congruence is again a difficult concept sometimes. So this idea of a congruent or an incongruent mood. So say for instance, that it fits again a lot with really what is or isn't appropriate. Say if this man uh told us he looks like this and if he told us that actually his dog had just died and he's just been fired from his job and he thinks that he's about to um please his partner. Uh but he looks like this and he says that he feels great. We would describe that as being incongruent because he's looking very different from how we would expect the other way as well would be if he looks like this. But tells us actually, I feel really low but is saying it with a huge smile and, uh okay, massive grin on his face. That's very incongruent. It's not appropriate, it's not in keeping what he's saying and what he's doing don't match up and that's an important thing to document and to be aware of if that's happening as well. Um Again, it's just something for helping narrow down the differential diagnosis and thinking about what else might be going on for someone as well. Okay, so now we will have a pause from me talking and we will watch a brief video. So let's see if this will work for me. If anyone has any questions, please do pop them in the chat as well. And we'll look at this first club tried, I think to get one where we can have subtitles. So it might be a little easier um to follow, especially if my internet connection is not good. So what we want to be thinking about this is what her appearance, behavior, mood and speech are like. Um So we'll see what you think and if you can't hear or see, then please do, let me know, sorry, we cannot see or hear some anything. Oh, thank you. Sorry. I thought someone said they could see. Uh sorry, let me make sure that it Thank you very much for letting me know. Yeah, what screen can you see at the minute? So at this moment, you can only see the any questions, the only the presentation, the question one? Perfect. Thank you. So let me share. Sorry, I think I did it wrong in terms of sharing the screen. Thank you so much for telling me. Can you see the symptoms and science, anxiety slide um screen now? Yes, perfect. Thank you. Okay. So this is a video on anxiety and just to warn people as well. So this is good because I had meant to mention before um it important to bear in mind how this makes you feel watching this uh makes me feel very anxious. So just as a warning to others as well. Um but important to keep in mind what her appearance, behavior and speech is like um as well as perhaps her mood, please do let me know if you can see this. It really is awful. It just makes me, it makes me feel really sick. Am I I start to get rid of uh my breathing, isn't, is it good? You know, um Actually feeling like I'm feeling now right right now. Uh It's, it's really hard to, to, to breathe. It's like I can't get air. Um God, my hands just completely. No, I can't get any air. Um So is that how that feels now? I'm really not, I'm not feeling well. Okay. Can you tell me what else is happening. No, I'm not feeling well. My arms and my hands are, they're feeling numb and they're really, like, tinkly. It's like pins and needles. I'm not, I feel like, I don't know what's going on. It's, it's, it's, it's horrible. It's, it's my butterflies in my stomach. I literally, I really don't feel well, I don't, I just swear I'm having, I'm having a heart attack. I swear. Okay. My heart is just, just racing, you know. Oh God, I'm sweating, I'm really sweat. Okay. So thank you. And hopefully now you can see the presentation again for them. I should just be share in my whole screen now. Perfect. Yes. Thank you very much everyone. Thank you. So, would anyone like to fair any thoughts on what I mean? There's a bit of a spoiler in terms of the description on the website is that this person is presenting with anxiety and with the symptoms of a panic attack. But how might we describe what her appearance and behavior is? Um brilliant. Thank you. Yep. So perfect. And there's a lot of really nice um sort of as objective and as structured descriptions as possible. So that's perfect. So, yeah, I'd say that she's appropriately dressed. There's no concerns about her appearance or behavior. If you could see her or smell her, you wouldn't think that she would have poor self care. She looks sort of, yeah, appears neat as someone has described perfect. It does appear restless, anxious as well. Definitely. And how we describe her as anxious as really important as well. So, exactly, she's rubbing her hands together. She's breathing quite heavily. She's speaking in very short sentences. She appears breathless. Um, she's agitated. It's complement. Perfect. So what she's saying and what she's feeling um fit together. There's lots of moving of her hands are very anxious hand movements. There's rubbing up her hands together as well. She's not able to be, um, you said comforted there as well. That's perfect. The reassured is the one I was thinking of as well. So, the really seems to believe that she is having a heart attack and she's clearly very anxious. There's no eye contact. Exactly. Or very poor eye contact. Um, she's stuttering. Exactly. We don't know that she's taking Codec from how she appears, but she certainly looks that she's breathing more quickly. Um, she can't sit still. She's very restless. Uh, there's lots of pauses and actually someone said that her speech is slow. I wonder what others think. I think her points, she's actually speaking quite quickly but she's just not saying very much. So, she is as typical in anxiety. I wouldn't say that her speech was particularly slow or drawn out. She's actually the words she's saying are quite quick but there's lots of pauses between what she's saying. She's repeating the same words. She's very agitated. She's very restless. Exactly. She's leaning forwards around. Exactly. Perfect. Um There's lots of really, really good descriptions there. That's brilliant. Thank you very much everyone. And so as we can see, she yes has anxiety and those she's describing the symptoms of a panic attack. I wonder if she makes anyone else feel anxious. Um It is definitely something that I feel watching her. It makes me feel really quite on edge actually. I almost feel like I'm holding my breath while watching her. Um which yeah, other people are saying the same thing and I felt it's worth warning not to try and put the seed in your head a few weeks, you feel anxious, but just because anxiety is a very strong emotion and it's a very powerful portrayal I think for this actor and the video, how would I describe her tone? So I think it's difficult, I would say actually that her, she, I think, I don't know if other people would disagree. Uh And this is a nice example of how uh quite subjective this can be really, I would say that her tone did go up and down appropriately in conversation. It wasn't that she was speaking um with a particular monotone voice or speech. Um but she, there were lots of other abnormalities with her speech. So she was speaking definitely rapidly and um with uh lots of pauses and I think they would be the main abnormalities. Stay there. Really? How do we differentiate from mania and with anxiety. A lot of it is on how people say things and what they say. So if you just write down those descriptions that she's quite agitated, she's quite restless, quite breathless. She's not speaking, speaking relatively quickly, but with lots of pauses in what she's saying, you could imagine that that could fit on Tomainia quite easily. But as we'll see from a clip of someone with media, there's a lot of other things that will go on with that. It's not just what, how people are saying, it's also what they're saying as well. And so yes, she would be more hyperactive, she would be saying uh more things in keeping with mania. So descriptions of anxiety and descriptions of mania as opposed to descriptions of anxiety. What she was saying there was clearly very anxious topic. Does that make sense? They will see a video of that as well. But thank you very much Natasha for asking that. But yeah, do let me know if that doesn't make sense once we see the video for uh mainly uh let's look at the video for uh low mood and then we'll move on and have perhaps a five minute pause. That's okay. So I hope, oh no, I was going to use a different one because this one's got some title's okay. So let's see how this goes because I think that works. Okay. Can you see this video screen? It's not playing as yet. Yes, perfect. Thank you. So, just watch a minute too. I can't concentrate. Hmm. Yeah. What about your memory? Have you had any problems with that? I think I'm forgetting things. Okay. Have you run into any difficulties in your job because of that? I have made some very serious mistakes at work and I'm very, very worried about that. What kind of mistakes did you make? There's a client who's been coming for years and I got the name for her dog wrong. Okay. And just so embarrassing. And I don't usually make mistakes like that. You sometimes you feel really bad about that, but we can all have our off days, can't remove that. You forget things. Do you think she understood? I shouldn't make mistakes like that. Okay. Uh Just not being worked okay. So I don't think we need to watch all of that video. Get a bit of a gist from that. So again, how might we describe this woman's a parent's behavior, mood and thoughts of the specific ones here? Really? I think that would be useful to think about the perfect yet so low. My monotone speech, hopefully, now that makes sense between the difference between that first woman and this woman. So the tone for the woman in the first video was really quite appropriate and normal. Whereas this woman, you can really tell her speech is very monotone, um that she's not making any eye contact. Exactly. Yep. So she's speaking quite slowly. As well. Yep. She looks perfectly appropriate with her clothing and someone said they look clean. Yep. She's got appropriate clothes on. She does have very poor eye contact. She's got folded arms and that's a really important thing because lots of people have said that she looks depressed. But that's because in part because of her posture. Exactly. So if we're describing just on her appearance and her behavior, but her appearance, she's wearing appropriate clothing, but actually the way that she's carrying herself, the way she's holding herself, she's got folded arms, she's very closed off. She's not making any eye contact. She's got her hands wrapped around herself. Perfect. Thank you, Lucille. Yeah. Um Oh sorry, I moved on a there we go. Excellent. Was trying to scroll through the messages on here. Perfect. Yep. She repeats herself as well. Um She's got very closed down body language. Yep. And as we talked about for her speech, yes. Uh um low rate of speech, very quiet volume, monotone and she described her mood as bad. She's feeling guilty. Um And that exaggerating feelings of self guilt is a really important one and we'll look at that when we think about thought as well. Um So she's yeah, otherwise coherent um speech with that too. So in terms of her thoughts, this leads nicely on to our next section. Um perhaps we could look at the next section and then have a five minute break that second with others. Um, that does lead very nicely from what were saying about these excessive feelings of guilt. Um, we would say perhaps that she has some abnormality of thought, but what she's describing is sort of the feelings of being so guilty. I don't know if everyone could hear properly, but she's talking about feeling that this was an absolutely terrible, awful mistake that she made it work because she forgot the name of one of her clients dogs. And that's actually in the ground context of things. Really not a particularly terrible mistake. It's not a disaster, but she's seeing exactly subpoena. You said it's a very trivial mistake. It's disproportionate and it's um it's that sort of catastrophic thinking that even though there's something that's actually really quite trivial and minor, she's got it in her head as being this massive, enormous topic. So would we describe that as delusional is one question? Um As a slightly leading question, we can leave that perhaps for the next slide as well. I'll leave that for you thinking about that. Perfect. Thank you, Miriam. Yeah. So your pre empting what I'm already just about to say. So, thank you. So when we think about thought, we think about what someone is saying what the content of their thoughts is, how best thoughts are structures, what the form of the thoughts is. And then there's this concept of thought manipulation or control where people can feel that their thoughts are being controlled by something or someone outside of their head, they can feel that thoughts are either being taken out of their head or put into their head. And that's something that seem more commonly in psychosis. But we'll look more generally about how you describe these abnormalities of thought. You can think. And again, I like my analogies because I like trying to make things a little bit easier to understand. You can think about the content of thoughts is like the story of a book. So it's what the plot is. It's what is being said in the content. In the story. The form of thoughts is how that story is structured. It's the grammar within a book. So while the plot might make sense, it might be a coherent story, it could be structured really badly. There could be really unclear grammar which makes it very hard to read and hard to understand because thoughts content isn't structured appropriately. It could be really all over the place with no coherent linking between the different sections of the story. But that doesn't change anything about what the fundamental story is. If that makes sense and then thought manipulation is like having text added or removed. So when people describe what their thoughts are like, they'll talk about how it feels. As I said that you thought that taken out of their head or put into their head, it's easier to think about this practically rather than an abstract. So we'll think about what people are saying, the thought content. What is it that people are talking about? And really this comes down to people's different beliefs or ideas and they can be held with different intensities. So, for instance, our woman in our previous, um, clip, she had a very, very strong belief that what she had done at work was this awful catastrophic mistake. What we don't know is how strongly she held this belief? Was it just a preoccupation of something that was sort of going on in her mind? Was it something that she was almost obsessing or having these compulsive thoughts about? It was definitely a worrier and anxiety. But again, how intensely held those are, is very hard to tell just from that clip. I think what we might describe it as would be an overvalued idea. But again, we would obviously want to know a bit more about her subscription, what happened because it's all dependent really on um the intensity to which she holds that view and whether it's unshakeable or not, is this just something that she feels out of proportion to reality or that she holds with delusional intensity? Is this a belief, definition of delusions? It's a false unshakable belief that is out of keeping with the patient's social and cultural background. Is this something that someone believes so strongly that they will not um be persuaded otherwise? And importantly, as we've talked about, it has to be out of keeping with their social and cultural norms. So I don't feel perhaps that the story about the dog name would really fit with the delusional belief. It's probably more of that anxiety or an overvalued idea, but still very distressing for her. Obviously, delusional beliefs can come in all sorts of different forms. And again, it depends on the content of what is being held with this delusion, uh intensity, what belief person has the paranoid delusional beliefs. The common one being uh seen in paranoid schizophrenia form of psychosis where people might believe that for instants, um, spy agencies or the police would be out to get them. We can have grandiose beliefs that are more commonly seen in, um, yes, perfect Merriam. Yes. A bizarre delusions in schizophrenia would, depends on the content of the delusional belief. But if it's a paranoid or persecutory beliefs, believing that you are being persecuted when you're not, that would be a paranoid belief. Grandiose seem more Romania where someone may have a belief that, um, they have a special power or like, they're somehow more grand is the idea. It's, um, an inflated sense or an inflated belief about themselves so that they have superpowers that they've been appointed by a deity or my God. These would be in keeping really with grandiose beliefs. Um, and I just skip through the other ones. Yeah. Thank you. Ahmed. That's really a paranoid belief is, um, it's not just being over suspicious it's got to be such a strongly held belief. It's got to be unshakeable. The person is not able to be convinced that it's wrong. So just a few other types of delusional beliefs that people can have. Arata manic is a belief that someone is madly in love with you. It's something that seem more in films rather than reality, but it's a very common portrayal in um certain TV series things as well that can happen. And it's a serious risk in terms of the stalking behaviors, delusions of reference in that something in the world has specific meaning for you. So for instance, people can see a particular um shape in the clouds and have a very strongly held belief that that means that God has appointed them to be the new Messiah for instances or some form of very strongly held false belief out of keeping with their background delusions of control as where someone can feel as though their body is not in their control, that their actions are not their own. Again, that's a really important one from a risk point of view. Religious delusions can often come into the others. But again, that's a relatively common one that someone can believe that they have been appointed by their deity or appointed by God to carry out certain acts or that for instances there, God is going to punish them or the better patient who believe that the apocalypse was coming as a result of their actions. And the holistic delusions are more commonly seen in a severe depressive episode where someone can believe that their body, you're part of their body is dying and that they are already dead. Again, this comes with huge risk concerns uh in terms of harm that someone may cause themselves thinking that already there dead or a body part is dead. Um So we'll see an example of grandiose delusions ahmed in our next video clips. Um So I'll save that with that. And then Merriam, you said a reference delusion again, we'll see that in our grandiose clip. So I might leave that for that discussion because I often find it's easier to think about these things uh in relation to a specific practical example rather than uh in theory, one example I could give of a grandiose delusion. Uh And it's important that we think in terms of uh it's got to be out of keeping with the person's social and cultural background, these beliefs because some people may well believe for instances as an appropriate religious beliefs that they are called by God to be a doctor or to carry out particular acts that may well be something they have always have. That's not a new belief for them that's perfectly in keeping with their social cultural background. It doesn't result in any concerning or risky behaviors from them. It doesn't result or come from any other symptoms or signs of mental illness. That's not a delusional belief. That's something that is perfectly in keeping with the person's background. The other important thing to realize is that delusional beliefs are linked with the person's social and cultural background. So for instance, there are certain examples of things that you only get at particular times and cultural places. So when I was working on an inpatient psychiatric ward in April 2020 we and the UK had the particularly big COVID outbreak and our very first lockdown in May 20 March 2020 apologies. And so this was in the context of the entire country shutting down because of COVID 19. At one point on the ward, we had to patient's, one of whom was manic with grandiose delusions and one who had severe depression with the holistic delusions, the man with grandiose delusions believed that he alone had the cure for COVID 19. And that if only we would let him continue his research, which was him writing bits of paper completely incoherently. It was there was no sense to it at all, but he was completely um I had this absolute unshakable belief that he alone held the cure for COVID 19. And if only we would let him get on with things, he would be able to solve this entire global crisis. Whereas our gentleman on award at the same time who had no holistic delusions believed that he was the cause of COVID 19 and he had caused the entire world to shut down and that, actually, if he died, everything would be better for the world. And so that was completely culturally bound. You wouldn't get those beliefs at any other time really in the world. But they were in keeping with that. But the belief itself was clearly abnormal if that makes sense. Um, sorry, someone had their hand raised. Yes. As'ad, uh, person, yes. Yes. The patient who had the grandiose delusion. Was he a person from a, like, was he a doctor or was he just a normal civilian? Yeah. Yeah. Just a civilian. I can't remember what his day job was but it was nothing medically related. Um, uh, it was, uh, totally bizarre and totally, uh, impossible and incongruous. It wasn't any. Yeah. But there was no, uh, element of fact that could be in there. It was a completely false belief but something that he held with complete delusional intensity. Um, and we'll see that in the video clip actually, which was so, also as I'd go for it, I think the person with nihilistic and grant use solution. I mean, I mean, it's just, this just came into my mind the way to, uh, calm them down is just to have a conversation with them. Right. Like how they are. Uh, I mean, if they're not thinking in the right manner, we take them in a step by step process that the things are not because they are like, for a nihilistic one we would say the COVID nineties didn't happen because they were, he was somewhere else this and that like this isn't his fault. And we tell him in a systematic manner in a technical manner, the how the pandemic occurs and how he is not alone, the reason of causing this and in the grand use as well, we might explain as well how the things he's like a writing in the paper. You might tell him that this doesn't work in a real life. But do these people continue to, even after explaining, they continue to think that that manner, they just accept it? No, they continue to think in that manner. And that's the reason why they were admitted to an inpatient psychiatric ward because they had so uh yeah, the, the man with mania had a severe bipolar illness and he was not, this is the kind of the principle really of the delusion. It's unshakeable, even if you sit someone down and you explained rationally and clearly to them, he was not able to follow the rationality. He did not believe the evidence that we presented him with. Of course, um there was no way of rationalizing and of making him see objective truth because he was so strongly held with this delusional belief and he was so unwell. So he needed inpatient treatment in order to treat his underlying illness that was presenting with these beliefs if that makes sense. Um I'm just aware of time. But I hope that helps. I just want to move on because I think, yeah, briefly, we look at the thought form and then we'll have uh just a couple of minute break. I think if that's okay, the thought form is how someone speaks. Their, this is another way of using the, this description is called formal thought disorder. So it describes the coherency and the structural organization of information that someone is presenting. We can only go on this on how someone talks. But it's very because of course, we can't read minds. There's no other way of accessing someone's thoughts, but it's very different from speech because what we're looking at is the structure and organization of how someone is conveying their thoughts. It's not the mechanics of speech in terms of what is it loud or quiet or one tone or more, it's more about like the grammar of a sentence if that makes sense. So there's different descriptions of formal thought disorder again. Uh it's possible to look up these descriptions. There's no need to remember them all at all. Precisely Merriam as well. Yes, flight of ideas. Something that's very commonly seen in mania as well. So these are the different forms that we get some incoherence is really the worst or the most extreme form where it's often described as word salad. It's as though the words are just completely job altogether. There's no link at all between associations between the thoughts that between the topics that someone is using, derailment of tangentiality is when things veer off point, there's no, it may start to be associated the thoughts and the topics that then they become very disorientated very quickly. There's no link. Then with the original topic, I'll show again a picture because I find this much easier to think about. Um Perfect. Yes. Thank you people for replying. That's brilliant. Thank you. So we'll look at a picture cause I think that's much easier to describe rather than thinking about these things in my situation, just as a example of people don't know chess. Uh So a non secretary in Latin literally means does not follow. So nights move thinking is sometimes used to describe when someone's thoughts move like a night in the chest pieces. So it appears illogical. There's not really any link and not know following in the topics that someone is talking about. So if we look here at this image, so we go from topic, a topic be this follows neatly in a line. There's no veering off in different directions that just follows a straight cause there's a link between into the topics. So this would be normal thinking. There's relevant associations and it's goal directed. So the bottom one, it does get from A to B where we want to go to, but it goes kind of around the house is there's circumstantiality to this that's over inclusive. It's including other topics that doesn't, don't need to be talked about the less relevant associations we reach the end goal, but there's a securities route. It's lots of thinking around the topic rather than going specifically there. Um And thank you Abril, we'll talk about that perhaps at the end as well in terms of how we um manage different mental health disorders. I'm hoping that there'll be lectures on anxiety and bipolar disorder. I know there was a lecture on depression, I think on Monday, Tuesday. Sorry. But hopefully they'll be lectures on those as well in terms of how we manage different psychiatric disorders. This talk is more about how we recognize them and how we describe them appropriately rather than how we manage. Unfortunately, it was just too much to cover in one topic otherwise just thinking as thoughts get more derailed, we start off at a but we end up at see, there's a much less of a link between the associations you don't reach the goal at all. This is very tangential. We go off topic. The person may start initially around where we think or expect them to be talking. But then things as I say, they're of public very rapidly and there's a description of flight of ideas which I think they're um you mentioned previously in the chat, this is something that seemed very commonly in mania. And again, this is where someone has a rapid speech. But the so that's to do with the mechanics of speech. So I can describe that in more of the speech area, but then thinking about thought form. So we would describe it as flight of ideas where it's as if they're just jumping from topic to topic and it just sort of jumps away from where you would expect the topics to go. And then our last one is a complete loosening of associations. There's no relations to the topics. There's an unclear goal. There's just very odd, erratic parts. It's almost like a word salad is the description. You just get random words at different times. It's very hard to impersonate and it's very hard to, um, describe unless you've seen it. I've only seen it very rarely but it's a very, uh, sort of striking finding when you do see it. I think that is a good time for us to have perhaps a four minute pause if that's okay. Uh, and perhaps we could join back again at just before half past 11. Um, just have a bit of a stretch of legs because I know you've got another lecture again at 12 as well. So we just have a couple of minutes pause. Um, and then join back just before half past 11 if that's ok. Thank you. Everyone. Hi, everyone. Yes, I was just having some problems with my computer. Restarting, joining there for me. Thank you. I hope everyone's had a bit of a stretch break and a chance to go up to the loo uh let's carry on and watch this video on mania, which I hope will answer some of those questions that people have had about how the SAS that someone, what the difference between someone presenting with mainly and anxiety might be, how we might think about categorizing those parts of thought. Uh and how we might describe speech as well in terms of um someone who is presenting a manic presentation. So hopefully this works with this video again. Do let me know if there's any problems with this video. Is that working? Okay? Hello there, Mr Riley. All right. My name is Doctor Betty. I'll come and see you called my GP sent you see you didn't come and Citrix artist because then you'll be come and see a psychiatrist, psychiatrist. Yeah. Yeah. Come and see you because you have time to listen to him. He's not had time to listen to me because okay GP. Mm. Uh Sorry that doesn't work. Let me just restart that again. There we go. All right. My name is Doctor Doctor Betty. I'll come and see you called my GP sent me see you didn't come and see a trick site because then you'll be come and see trick cyclists psychiatrist. Yet you come and see you because you have time to listen to. Yeah, he's not had time to listen to me because okay GPS and doctor, he's very clever. Can I just not, sorry, we'll get there in the end because you have time to listen to. Yeah, he's not had time to listen to me. You see? Okay. GPS. And doctor, I don't, he's very clever, very clever because he's not, he's not, he's not okay. Get into this. You see. Well, let me write, talk about, he talk this into some time. But then yes, sometimes he doesn't, can I just clarify why, why, why you're here and why I'm here? I'm in the emergency clear today and your GPS asked me to see. Is that, is that right? Well, yeah, because I've got to tell you about this. Okay. And this, because it's important stuff in it really, really important before we start with that. Can I just ask you what would you like me to call you mister names? Names of game's over names? That's just too good. Okay. Come with John John. Yeah. Okay. What's your name? I'm Dr Boediono. Your proper name. My name is, you've got my name. You probably, your name is not a doctor at work. I'm Doctor Betty. Doctor doctor doctor diddly downwardly Dane. Good. Do you watch? That's fantastic. Okay. Now, uh, can I ask you how old are you, John Doe? Only as old as a woman you feel? Are you right? Okay. You know what the man's artist to his stomach? Oh, yeah. How old would that make you to your soul? Nice bit of soul. Yeah. Right. A bit of fish. Found, I have hungry. You got your food, any food around here. Well, down there you got any food, I'm starving now, they won't be able to get you any food, should we? Perhaps? I'll tell you what I think about going back to the minute she is important. Okay, about this. Ok. Tell you what. Tell me a bit about this then. Well, this is, this is the work I've been doing. This is really important and it's more cure for cancer. Okay. It's all written down here. It's not being done, it's here and it's only your books. What I get from the papers is I get, I get some clues as to what I'm supposed to do and I'm supposed to get the other clues to hone it down and come up with a final thing, John has all of this been going on for ages now. How long the ages? Well, I've been up a week, a week but this week I've been working really hard because we're going no longer than a week. But I've been working out really hard for this week cause you use all the numbers. You see numbers, you have to find out. Am I right in thinking you normally do a different job? Yeah, I'm a mechanic. You're a mechanic, mechanic. Okay. Manic, mechanically called manic mechanic. Yeah, it was made my made Dave. Dave, I show him this and he told me he told me to go away because it's bonkers in fact, he didn't, he didn't say go away then told me fuck off. Okay. So thank you. Hopefully, that's helpful there between the this gentleman's presentation of the actors presentation here with Mania. I really like these videos. Um People have a chance to look them up of the psychiatric interviews for teaching on youtube by Nottingham University, a really good resource. So that's well worth a watch if he wants to watch the full video, which may go and it does go in a bit more to management as well. I think as someone was asking. So hopefully that's a nice demonstration there of a manic presentation. So I don't know if people want to um their thoughts on his appearance or behavior or any of those aspects. The thought is the particularly important one. So, yeah, thank you. So he's dressed in bright colors. He's got quite disorganized hair again. Who knows how much that's his baseline for him. Uh He may well just like colorful clothes, but it would be useful to know if that's unusual for him to dress like this. He's quite agitated, he's quite restless. He has very fluent speech. He's very talkative. He's very hard for the doctor to interrupt and what we think about what he's saying as well. So it's not just that he's quite pressured in speech. Yeah, he's got quite a flight of ideas. It's that lost association of thought as you said. I, oh, so he goes from topic to topic and there's that word play there as well. So, trick cyclist, instead of psychiatrist, food for the soul, then he talks about, sold the fish, then talks about being hungry. So you can see that there is a link between those thoughts, but they're quite loose, the links between them. And he jumps from topic to topic very rapidly, far more rapidly than you would expect someone to as is appropriate in conversation. Really, all of those points are exactly right. Thank you. Any thoughts about the delusional beliefs that he might have began? Yeah, he's very easily distracted, um, delusional belief of the cancer. He said the cancer notes he had. Thank you. Yep. Perfect. So I couldn't quite see who was saying that. But yeah, that's brilliant. So we've described those as definitely grandiose beliefs. He's putting together this um delusions of reference. He's putting together these odd numbers that he reads in the newspaper that he thinks have special meaning for him in order to be able to put together um to then come up with a cure for cancer. And as we were talking about before, it's that he is a, he's a car mechanic. This has nothing to do with his day job. It's very clearly delusional belief rather than actually that he has some kind of cure for cancer. I hope that makes sense in terms of the thoughts. So that's his thought content. We would say that he's got delusional beliefs. It's not just overvalued ideas. Daniel say they could be overvalued, but actually, if we were to watch the video for longer and if we were to hear him talk longer, they're very firmly held beliefs, unshakeable. Regardless of what the doctor says, he's not going to change his mind. He thinks that he's got the cure for cancer and there's nothing that she says that's going to persuade him otherwise. So that's a proper delusional belief. It's not just overvalued. Um Bob and the way that he's saying, so that's what he's saying. And the way that he's saying it, we would say that that was flight of ideas. He's got, as various people have mentioned, he's got the loosening of associations and he is um speaking very rapidly that, that fits with the flight of ideas, description there. Bab I know and I'm sorry to find, it's hard to hear what he's saying. Um There is a version where it has subtitles. I'm sorry that didn't come up here. I would definitely recommend people watch these videos if you find this useful. Um The videos have subtitles as well and um sections, but that's another important thing to reflect on. It is very hard to hear what he's saying. I've seen this video a number of times and I still find it hard to hear because he's speaking very rapidly and he has a reasonable accent as well that makes it harder to hear, but that's a useful thing to reflect on as well. That that's um difficult to follow what you're saying as well as to here. Okay, just to finish off, we'll think about perceptions. Um Thinking about uh the difference between, of course, yes, I can give the videos um link for the videos. I Oh yes, they're thinking about perceptions. If people look at this image and look right in the middle of the screen at the middle of the circle, does it look as though it's moving for anyone else? So that's just something that I can see. You've got a few people. Yes. So um it looks as though it's moving further people. Um So thank you maha just so briefly touching on that. So these ideas, do they come suddenly, does it come from an experience like someone who may have cancer, for example, as a close family member, they usually will develops, as this gentleman said, it developed over the week because this is the sort of onset of his um delusional beliefs and his illness that mania is triggered by lack of sleep as well as that being one of the kinds of symptoms and lack of sleep as well. Um There may well have been some kind of external q for him to start having thoughts about cancer, but that doesn't have to be at all. People can come up with these thoughts and delusional beliefs out of keeping with anything else going on for them. It's, yeah, there's, there's no necessarily reason for the link between it. So just this is a, a very silly example. So this is a visual illusion where if you look at the center of the screen and sometimes it can look as though it's moving for different people. Another type of an illusion is this um Thank you, ma no worries. So this delusion, if we look at the squares shaded lettered A and B, they look as though there are different shades of gray and they look as though they're very different colors. But actually, if we see with the tube put together, they're the same shade. It's just that the way that we perceive the image looks to our eyes though they are separate rather than separate colors rather than the same color. But these are illusions. These are optical illusions which are normal and we're not all hallucinating. We're not all having perceptual abnormalities, but this is a completely normal experience where you misperceive an existing stimulus. If this makes sense, this is an illusion which is a misinterpretation of a stimulus, it's not a hallucination. So, hallucinations or something very different and very precise, they are a sensation or a stimulus that has does not exist. It's a perception abnormality which is the sort of the brain's generation of a new stimulus. It's not that we misperceive an existing one like in an illusion. It's that we generate a new one where there isn't anything else before, if that makes sense. So this can happen in any modality. So in hearing, seeing a touch or feeling or factories, smell or gustatory is taste. So it can be in any type of um sense that you can experience a hallucination. The most common in psychiatry for a sort of primary psychiatric problem would be auditory hallucinations that's most commonly seen in psychosis where people lose touch with reality. This can be in either the second person. So where people hear voices that say you're bad or you're doing something or in the third person, which is where it's about the person. So often, this would be a couple of voices talking to each other about the person. So if I were hearing it, they would say she is doing X or she is why um people can also hear an echo, which is where they can hear their own thoughts, but being spoken aloud by someone external to them. And they can also experience something called running commentary, which is very unpleasant. People describe where they would hear voices, describing every action they're doing. So, um as you get up in the morning, someone might hear a voice saying she's waking up, she's picked her slippers on, she's brushing her teeth, she's washing her face, it's very unpleasant and very intrusive. And you can imagine links with those delusional beliefs that for instants that you're being persecuted or that you might be being watched or that people might have cameras in your house. For instance, if you can hear a commentary of what's happening for you and command police nations is another very unpleasant one as well. So where people can hear voices telling them or commanding them to do certain things okay site just moving on in our last few minutes as well. Just to finish up, we'll think about the other bits that we would do. At the end of the mental state examination, we think briefly about cognition. We would want to know whether someone was oriented to time place and person, what their attention is like the concentration or their memory. Often we can assess this more informally in a conversation if we're talking to someone for a half an hour and they're able to concentrate on what we're saying and to follow what we're saying and hold their attention, then it's likely there isn't a problem. And often we don't more formally assess this. We would formally assess it by doing one of these memory tests I was mentioning at the beginning, beginning. So something called the MMSC or marker, the ace three. These are all sort of formal memory assessment tools that are used to assess all these aspects of cognition. And thank you very much, madam, your pre empting me again. That's perfect. And just to mention, there is a frontal lobe test is something that we want to measure separately as well because it's not formally tested. Well, in those other assessments of cognition. With the MMSC insight is a really important one in psychiatry. Quite often people will talk about insight being present or not actually more useful is to think about what degree of insight someone has. So an insight just means what someone's awareness of their illness, what are their attitudes towards treatment and what their awareness of their own symptoms as well? So do they have insight into their condition means? Do they understand? Do they really know? And are they aware of what's going on, what the advice of the doctors would be in terms of treatment and what really their symptoms are as well? So we often people somewhat, I have a short hand if you will say insight, present or insight absent, but it's a far more nuanced and complex topic to that. It's about to what degree do they believe these things? So for instance, you might have someone who has depression who is very able to sit down and say, yes, I know that I have a depressive illness when it starts, I realize that I eat much less. I sleep much less. I feel very though I don't want to go out and do things and I stop enjoying my day to day activities. So there's a lot of self awareness of symptoms. There, there's an awareness of what the illnesses. And they may well say I know that when I've had this particular antidepressant before it really helps me. And so I know that when this happens, I will talk to my doctor and I'll request this medication. So there's a very clear attitude towards treatment there as well. Different psychiatric disorders that can present with a lack of insight might be mania, for instance. So our gentleman in the previous video, he did not think he was unwell. He thought that he had this great cure for cancer and had these wonderful ideas. He had no awareness into his illness. He didn't have any awareness that what his experiences were, were actually symptoms of mental illness. And if we didn't watch that bit of the clip, but it's actually pretty. Um you would guess if he was asked about treatment, why would he take any medication because he doesn't think there's a problem. So why should he different ways that people can describe how someone might have um insight, someone with mental health problem might say others tell me I have X. So for instances, it's our gentleman with, I had some treatment. He might say, oh, someone told me I've got me know, someone told me I've got bipolar disorder, but that does rather suggest that he doesn't think he's got it himself if that makes sense. So that's a useful indicator. If someone's just describing what doctors have told them, that doesn't really suggest that they have much of an insight themselves, the sort of, you know, probably a greater degree of insight would be, I understand that I have bipolar disorder or whatever the disorder would be because of, and then being able to list the symptoms and the reasons why they understand that they have this particular disorder. And the important thing is the role of medication and treatment and the role of more engagement with the team to be able to help manage these symptoms as we're talking about. That's the really important thing we're able to recognize these difficult um psychiatric presentations. Now, once we've done a mental state examination, but then the next important step is okay. What do we do about this and how do we manage these disorders and then went to finish off for a, a mental state examination. We would want to think about capacity risk and formulation risk is a really important thing that comes into all psychiatric assessments that we do. Um And mental state needs to be seen alongside psychiatric history for a full psychiatric assessment. Important for us to be aware that it's a snapshot in time. It's not a diagnostic or predictive examination that we do. It's important just to tell us really how things are now. And the other useful thing to remember is that when we're doing a mental state examination, it's a conversation. It's not a checklist. We wouldn't start by you asking the person. Give us an example of your speech. So I can document how you're speaking. How is your mood and going through very formulaic Lee. We would want to have a conversation exactly as we've seen with all of these videos that we've watched. It's not a checklist, it's not a tick box exercise. It's information that we gather and document in a structured way. But we gather the information by having a conversation with someone about what their experiences are, what's going on for them and then understanding how that might be different from previous experiences as well. Just looking at questions because there was a question from someone are depressed patients' usually aware about their symptoms, not always at all. So uh that sits in quite nicely with rules question beneath. If patient doesn't have insight, do they have to be an inpatient? No. So you can have incite and be an impatient, you can have incite and be an outpatient. You cannot have insight and be an outpatient. Still, it does depend on what degree of insight. So actually having said that our gentleman with mania probably wouldn't take medication. It's amazing how many people I've seen with psychosis, for instance, who do not agree that they have a psychotic illness. But perhaps they might realize that at different points in time when they don't engage with the mental health team, they really struggle with their sleep and they feel really unwell and oh yeah, they just feel really rubbish generally. That's when they have perhaps a psychotic relapse. But their understanding of it is that it's because they have poor sleep. And so they may take their antipsychotic medication because they think it helps with their sleep, which it does, but they're not taking it because they think it helps with the psychosis. So, for instance, people like that, I've had a number of patient's who were very willing to engage with the community team, they came to their appointments, they took their medication, but they didn't believe that they had schizophrenia. They thought that they, you know, we were overreacting a little bit, but uh from the patient's point of view, sorry that they were happy to go along with what we wanted and to keep taking their medication, even though they weren't really convinced it needed to be, be done. So you absolutely don't need to be an impatient. If you don't have full insight, you just need to be able to work with someone in a community setting and people who are depressed will not always have insight and not always have a full appreciation. So for instance, the patient I was speaking about who had very severe depression with psychosis and had me holistic delusions where he believed that he was the cause of COVID 19, he fully, very, very strongly believed. But if he died, COVID 19 pandemic would be over. And that actually as someone was asking before, there was no amount of sitting down and rationally discussing it with him and explaining the nature of my old diseases, there was nothing along those lines that would have persuaded him just from words and talking. He was not aware that he was severely depressed. He didn't believe us. He thought because he had these psychotic experiences, very strongly held delusional beliefs that he just needed to die in order to make everything better in the world. And so he needed to be treated as an inpatient because he was at such a risk of harming himself. I'm sorry. I said, I think you had your hand raised. Uh Yes. So that nihilistic payment might also be very suicidal. Izabal, a marginal suicide at him. Yeah. Yeah. So he, that was why he was an impatient was because he was very suicidal and he believed that he needed to die in order to cure the world and to save the world. Um which you could argue as well. Just getting a psychiatrist filled with nuance and subtleties. You could argue that that's quite a grandiose belief that you could save the world just as one person. Whereas most people uh would realize that actually a little impact that would have on global politics, just one person individually, but he was very severely depressed and that was not to complicate things. But yeah, I hope that makes sense from that point of view. I will just find the link as well. But um so I was asking for the videos. Um Please do let me know if you have any other questions. I hope that I've managed to see all of those questions that we've gone through. Um Well, and that was my last point is just that quote, the patient often work really well. Um And make sure that you are able to try and paint a picture for someone who can't see the patient who doesn't know them, hasn't seen them so that it can be used as a comparison as well. So I will stop sharing and I think while I was asking for that video link, so I will send particularly that one for mania because I'm sorry that that was hard to hear. Uh I know his accent is quite hard to hear as well. So there's the link for the mania um scenario there. Um Thank you very much everyone and um please do let me know if you have any questions. I know we've got a few minutes cause but I wanted to leave you a little bit of a break before your next lecture as well, but lovely to meet you. Thank you very much, so much doctor just to let everyone know the next session starts in five minutes and it's on road traffic collision extraction. Uh huh. What about the certificate?