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Should we wait for? No, no, I'll, I introduced it and we, we can wait once we're live, but I'll do an inr now. Yes, I'm on call that if, if I get a call I need to answer, then, uh Provena will continue if I get a call. Right? Yeah, thank you. So, hi, everyone. Welcome to the last session of the Mra prep series by FT SSE M. Um, final session for this weekend is psychiatry. So we've got two registrars in the area who've kind of agreed to come and give you some teaching. Um, we'll just give it another minute or two in case anyone's still having a little break from the last session. Er, but then we'll start shortly. We'll do questions at the end of this session. So if you have any questions, uh, if you can hold them to the end, but if you put them in the chat, either way, we'll look at them at the end. All right. So if we just, uh, one minute and then we'll begin just in case anybody's going to the bath. Sure. Sure, because we can't see the screen. We are only seeing that slide So, if you, if one of you just tells us when to start, we will be happy, isn't it? Yeah, if we have time, we can just go through this, do this. All right. I think we can start. Hello, everybody. Uh, my name is Doctor PTI. I'm one of the higher trainees registrars in psychiatry in Derbyshire. And this is my friend, I'm Ira. I'm also one of the higher trainees in, uh psychiatry. Today, we are going to provide a brief overview of psychiatry as you know, it's very difficult to cover a lot of psychiatry in 45 minutes. So what we do, uh what we are planning to do is give you some pointers so that you can read around the topics and come back to us. Uh like basically these slides, if you have any questions, you can come back to us with any questions if you have any really burning questions. Yeah, you can come back to us later as well. Yeah, so these are very quick pointers. Most of them are common sense, but I think it it needs repeating. It bears a bit of recap before exam. The obvious, the very obvious is please read the question. Well, uh it's, it's quite staggering how many times we don't read the question? Well, so please read it. Well, go through previous questions and read around the topics and the not so obvious are like, you know, if you have some, some situation if they have a scenario in the question, consider your safety in the question. And then the next thing would be considered patient safety. After that, you have to think about the guidelines that is to get at the most obvious answer. Think about the most problem because maybe two or three questions answers might seem right. But think about the most problem answer. And also think about the setting where you are because your answer also depends on whether you you are in a public space like a city bus or in the GP surgery or in a where a lot of equipment is available. So think about the setting, there are some broad categories in psychiatry. Again, this is not an exhaustive list. Um this is like the broadest categories we can divide them into. Uh first thing are mood disorders, mood disorders, uh include both low mood, depression and mania. And sometimes what we call is bipolar, which is the oscillation between depression and anxiety and mania. Next comes the anxiety disorders, generalized anxiety, phobia, specific phobias. All these come under anxiety disorders, psychotic disorders. Um psychotic disorders can be anything like schizophrenia or something which is transient psychosis like psychosis due to drug use that can also be psychotic disorders, personality disorders, developmental disorders, developmental disorders are um again, a separate category, we will uh we have a separate slide on it where we will go into a little bit more detail about it. And addiction psychiatry where we talk about substance use. Um and problems coming from substance use, cognitive disorders are disorders which are typically diseases of old age, but they can also be sometimes early onset management considerations. So the main considerations are before we start any management of psychiatric illness is to consider physical health differentials. Um An example of this is depression, depression symptoms like depression also occur in say, for example, hypothyroidism, unless you correct the thyroxine levels, there is no point in treating them with antidepressants. So that's something we have to think. And then we also have to think about substance misuse. As I have just alluded to alcohol use or some drug use can mimic psychosis, post alcohol use, people can have low moods which can mimic depression, prolonged or chronic drug use because of all the social sequelae that cause can also be similar to depression. And when we are actually formulating a management, it's always important to consider biological, psychological and social parameters. Uh That is when our treatment becomes holistic antidepressants. Now we have started talking about medication. Yeah. So, antidepressants are the first things we are talking about. Yeah. So antidepressants that most of the antidepressants work by increasing availability of the neurotransmitters like serotonin and noradrenaline in the synaptic junctions. And we have different classes that commonly used once um the SSRI is used to se uh selective serotonin reuptake inhibitors. Um There are um several examples that commonly use ones are uh cetra, FLUoxetine, citalopram, aci those kind of medication. So, uh according to nice guidelines that uh the s are the first line antidepressant we use that we are uh say first for example, that I saw one of your previous questions, if somebody has heart problems that uh sertraline is the safest medication uh to start with. Uh and SSRI s common side effects are uh related to gut nausea, gi symptoms, anxiety and uh sexual side effects. Uh Another class is uh SNRI S examples. Uh common use. One is Venlafaxine. Uh mm The common side effects. Again, anxiety, arrhythmia, confusion, hypertension, sleep disorders and sexual dysfunction. So, if you are going to start uh somebody with SNRI, I ask that whether the patient has hypertension or previous history of heart problems, any arrhythmias, then then you need to uh be cautious with Venlafaxine. The third uh class is tricyclic antidepressants. These are the older generation antidepressants that uh like amitriptyline, amitriptyline. Mm traZODone. Uh they are also very effective antidepressants but they have some um uh side effects mainly that as antimuscarinic effects, uh they can be make you sedated, weight gain, constipation, uh those kind of side effects um and uh they can cause a QT prolongation. So uh we know that people with depression, sometimes they take overdoses. So if they take tri uh tricyclic antidepressants as an overdose, there is a risk that um they can even die with uh uh cardiotoxicity. Uh Yeah, as I said common side effects are arrhythmias, dry mouth, blurred vision, constipation and weight gain. And now that uh I'm going to talk about antipsychotics, antipsychotics. Also, there are two main classes. Again that typical, these are the older generation, what we called first generation antipsychotics. These common ones are haloperidol. Uh again, these are effective and very potent antipsychotics, but they have some side effects like extrapyramidal side effects. We will talk about extrapyramidal side effects in another slide qt prolongation. So it is important to take an ecg before starting haloperidol, uh sexual dysfunctions and sedation. The newer second generation Lantus, what we call atypical lentic cortis that they are examples are risperiDONE, OLANZapine, QUEtiapine, ARIPiprazole, and cloZAPine. I think you have heard about cloZAPine. It is a um we use cloZAPine in treatment resistant psychosis when we have tried uh two different antipsychotics uh from first generation and second generation. And but still, if patient is still presenting with uh symptoms, we can consider closapine. It is an effective medication, but it comes with a lot of side effects. So we need close monitoring. Um atypical that new generation antipsychotics, they have less extrapial side effects but that they have different types of um side effects, set of side effects, side effects, what we call metabolic syndrome. Uh so they, they can increase weight, it can cause in BP, blood sugar levels, weight gain. Uh those are the uh risk with the conation antipsychotics. So we are going to talk about EP SAS. As I already said, we ha we don't have enough time to describe in detail how VPs occur, what is the treatment and everything? But what we can do is touch on them. So there are four kinds of E PSE S. The first one is acute dystonia. Next comes akathisia or restless legs or parkinsonism. Parkinsonism is symptoms like Parkinson's which are because of antipsychotic parkinsonism. That's the difference in, in exam. You can have uh questions which would say Parkinson's disease. Parkinsonism don't, don't get caught out by these things and tardive dyskinesia where most of the moments are slowed down. So I would really, really urge you to spend a bit of time and familiarize yourself with this. Uh I, when I was preparing for mass, II had uh prepared a table where I had name of the symptom and how, what are the presents and what we do for treatment that would be good. Procyclidine is one thing which we give but also again, when to give it, how to give it. It is important I think to know about these things, there are two other psychiatric emergencies. Um Most other psychiatric illnesses can be treated in the in slowly, in taking time, but there are two other emergencies when I say to other, not all s are emergencies, only acute dystonia is an emergency. Rest of the things can be treated slowly. Um The other ones are neuroleptic malignant syndrome, which is because of any of the antipsychotics and serotonin syndrome. And you have either too much of serotonin because of the SSRI S or S MRI S or you have given some other medication which is also excreted through the same pathway. And that results in accumulation of serotonin in the body mood stabilizers. Now that we have talked about antidepressants and antipsychotics, the next class of medication that's very commonly used in psychiatry mood stabilizers. Um Most common example is lithium and most frequently used is also lithium. Uh lithium has a very narrow therapeutic index. Um that means that you give a little bit more and you get all toxic side effects, you give less and it doesn't work. And also another point there is that it is metabolized. Its metabolism is quite unique. Um If two people have the same dose of lithium, their serum lithium levels would be different. So that means it requires quite stringent monitoring and you got to be very well aware of the toxicity features and side effects. Lithium is excreted through kidney and long term effects on kidney and thyroid have to be washed out for every every three months. Uh When we do lithium levels, it's advised that you also do kidney function and thyroid function test. Lithium monitoring. In the beginning is after every dose change, that is at least once every five days or seven days when the dose is changed. Once the dose is stabilized, you repeat it after one week and then it's three monthly or six monthly depending on the confidence. So that's about lithium. Um It is very well used. Uh anecdotal evidence is that it is quite useful in suicidal intention. And uh in when there is quite a lot of harmful behaviors, sodium valproate is the next medication. Uh It was used quite um quite uh popularly uh a while ago, maybe 1015 years ago, it has fallen out of favor because of the teratogenic side effects. Now, currently, if we are using sodium valproate in a woman in deeper age, we have to make sure that they, they are on quite significant contraceptive um treat therapy. And uh we call it never even, never even uh events which were prescribed by nice, which were listed or by n uh as to never happen in any UK um medical set up. So I think I would ask you to maybe do download the document. It is like 10 to 15 pages long and read about the never even events. So it can be something in another specialty. You might get a question from another specialty, which would be another event. So I would say it is important. Other side effects are hair, fall, weight gain and hepatic disorders. Sodium val is excreted through the hip through the liver. So, hepatic disorders are something to watch out for. It is also important to watch out for other medications which use the P 444 50 system because sodium valproate also uses the same system. And uh antipsychotics are also used as mood stabilizers, particularly the second generation ones like OLANZapine and risperiDONE. They are also used as mood stabilizers. Now, we are talking about substances, there are a lot of substances of abuse potential and addictive potential. Of course, the scope of this um lecture would be far below covering all of the substances that can be used as drugs, drugs of addiction. We are only concentrating on alcohol and opioids. So what alcohol does is it increases the inhibitory neurotransmitter gaba and decreases the excitatory neurotransmitter, glutamate. So, thinking of this would be helpful in thinking when you're thinking about the withdrawal symptoms because it has that inhibitory effect. When it's withdrawal happens, you'll have this excessive movement that's like hand tremors, sweating, tachycardia. You would also get nausea, vomiting and headaches, loss of appetite, irritability, restlessness, loss of sleep. This in severe form is called delirium tremens typically occurs about 72 hours. Post last dose of alcohol, last last drinking episode. Uh delirium tremens is an emergency. Alcohol withdrawal is treated with benzodiazepines. It is very important to get on top of it and treat it because it can also be a um something which would cause loss of life next. And we also do thiamine. No. Yeah. Yeah. No. To prevent one case encephalopathy. Yeah. Thiamine and B complex. Yeah, opioids, opioids. We have a lot of opioid receptors in both C NS and PNS opioids, particularly work on the new opioid receptor as agonists of them, they are very useful in pain management. But unfortunately, the flip side is they have extreme addictive potential. Um withdrawal would cause nausea and vomiting, anxiety, insomnia. Uh they would feel hot and cold perspiration. Sometimes they would feel some um itching sensation. They, they typically describe under the skin. That's very typical because if we get itching, we would get on the top of the skin. But if we are withdrawing from opioids, it would some, they describe it as something is itchy under the skin, perspiration, muscle cramps, watery, testosterone, eyes and nose, diarrhea. Um So this is what happens with opioid withdrawal. We try to give opioid substitution therapies in, in the in form of methadone and buprenorphine. Again, that has to be carefully calibrated like lithium dosage. This is very individual, not the same dose works for the same kind of addiction. So it has to be very carefully monitored and only given in specialist services. These are two most common substances of abuse. But we would urge you to read and get a basic understanding of other substances that we that are common like cannabis, cocaine and amphetamines. Uh try to understand the mechanism of action. What are the withdrawal symptoms? What is a neurotransmitter that is activated or slash inhibited? And how does it affect the reward system? Because that is what is causing the addictions. Yeah. Now I'm going to talk very briefly about developmental disorders in psychiatry that mainly that we, especially in CAS that we see patients with autism spectrum disorder and ADHD, so that autism spectrum disorders name suggest this spectrum. So uh and read about uh heritability and comorbidities usually that um people with AD and AD HD that they are more common comorbidities and um asd that autism, that typical presentation, you know, includes that problems with social communication. So that, hm parents will say that that uh they have limited, my child has limited friends or that uh they do not uh keep eye contact. Uh sometimes that they do not use proper language. Sometimes they use special words for the uh special meaning and they have restrict, Children have restricted interest um like, you know, red colors, car or uh they have very particular interest and then repetitive behaviors and uh Children with ad that uh in MC gives that if there are something that uh about speech delay, especially uh within first three years of the age that if parents have noticed a speech delay that goes towards ASD uh and then AD HD that it stands for attention deficit hyperactivity disorder. Uh So typical presentations that they will have problems with hyperactivity, inattention and impulsivity and to diagnose AD HD that you need to have uh uh these difficulties affecting their ability to, to function. Uh And in a two different setting, their parents will say that uh uh you know, at home and school that at both places they need to have these difficulties. So try to read little bit about conduct disorder as well as a differential diagnosis and learn about uh pharmacology as well that ADHD that we commonly use methylphenidate. And uh so read a little bit about methylphenidate and apart from medication, uh both a uh ad HD and the AC also that other um parental supporting system and how to manage their behaviors, those things are important. And in psych entry that we have a different specialty uh called I DD. Intellectual, what is it? Disabilities, disorder? Yeah. So previously, we call learning disability. So there are groups, mild learning disability, moderate learning disability and severe learning disability. So uh uh if you have time, try to uh learn a little bit more about learning disability of functionalities. And so when we say mild, moderate and severe, it's not just about the persons like you. Yeah, it is about their functionality, how they function, how they are able to sustain their like basically how are their independence and areas. Yeah. Yeah. So, dementia. So, dementia is an umbrella term. So uh so we, it is a neurodegenerative disorder affecting the brain. Uh usually the common symptoms is that people will come with problems with memory but to diagnose dementia that we need to have uh uh not only memory impairment that impairment in other cognitive functions as well. For example, attention concentration problem solving visual spatial ability. Uh and uh that impairment should uh severe enough to interfere with daily life. So they, they can't uh fun uh function as before. And these symptoms should last for more than six months to diagnose dementia. Uh There are d various types of dementias. Alzheimer's vascular live body, frontotemporal, uh and uh mixed dementias as well. And then, uh there are other types like that. People can develop dementia due to Huntington's disease. Parkinson's disease. Um HIV syphilis, the there are and alcohol. Uh, there are other, uh, illnesses that, uh can cause dementia. And, uh, when we talk about dementia, try to learn a bit more about antidementia medication. There are two main types, acidic cholinesterase inhibitors and memantine. These medication are not to cure dementia, but to slow the progression of dementia and to improve their quality of life. And there are some evidence that, uh, these medication will help with their behaviors as well. Um, and dementia is the most, uh, the killing illness in UK. Um, uh, what else? And, uh, read little bit about delirium as well. That what is the difference between dementia and delirium? As Praveen said that you can make a table and, uh, try the differences between dementia and delirium onset presentation management. They are different. Yes. And, uh, this is another disorders that we talk. We see patients with personality disorder. We saw that there that you had some questions around personality disorder in your previous papers. So there are many times that uh uh that you can easily remember like three clusters that we we just said like sad, mad and bad. So cluster personality disorders uh that paranoid personality disorder, cryo personality disorder and cryo. So they are mad and cluster B antisocial histrionic narcissistic eu PD, they are bad and then avoidant personality disorder, obsessive compulsive personality disorder and dependent personality disorder. They are sad. So just read around the most common ones. What are their common presentation? Uh And then because I saw that there were some questions that uh you need to understand that when they gave some symptoms, what is the diagnosis? Uh I generally don't like quoting Wikipedia but uh for personality disorders, Wikipedia has a good page. If you just type personality disorders on Wikipedia because you, you have an exam and you don't need extant details about each of the personality disorders. You need to understand the chief presentation. I would suggest. Go through that. Yeah. Yeah. Yeah. Then psychological therapies again that um uh that we in psychiatry, we use holistic approach when we are treating with patients. So um that we, we use uh biological, psychological and social aspect of care. Uh I think that is the beauty of psychiatry and you can also consider psychiatry as uh your future career that so medication that we talk before and then uh the the psychological therapies that there are different modalities. Uh These are the common ones, uh CBT stands for cognitive behavior therapy. So as uh as, as name suggests that, that how that our thinking can affect our behaviors, uh and our thoughts and emotions, that's what that we uh try to explore during CBT and try to alter the relations between negative thoughts and results and behavior. We try to help the patient to understand that when they think when they have constant negative thought, it can affect their behavior and feelings. So when they understand that they can change their thoughts and behaviors, mm So D BT stands for dialect, dialectical behavioral therapy. Uh that is main use for patients with emotionally unstable personality disorder. So as NA suggest that E UD patients has problems with uh regulating their emotions, they can't uh tolerate distress. So they use me lead up to coping skills. They come with overdoses, self harm and they have problems with uh maintaining relationships. So that's why that uh this therapy will help them to uh learn some techniques to regulate their emotions and how to tolerate their distress rather than doing any self harm acts. And um uh this uh uh therapy will help them to have better relationships. So another one is E MDR. It stands for eye movement desensitization and reprocessing. This is mainly useful in PTSD. PTSD stands for posttraumatic stress disorder. Uh The people that who had experience very traumatic experiences can develop PTSD and another therapy is family therapy. This is especially useful in uh when Children present with mental health problems. So, in family therapy that all the family members can attend the therapy sessions and it will give a safe space for the every family member to express their emotions. Uh So pe other people can understand where they are coming from. You can understand that when a child has a mental health problems that it makes huge anxiety and stress to parents. So, so family therapy will help family to come to a safer place and discuss and come to a conclusion to see how best that they can help their child. And another one is psychodynamic psychotherapy. Uh It is psychodynamic psychotherapy usually takes longer time. We will have long many sessions. Uh But uh this therapy will help uh patient to understand uh they are unconscious thought processes. There are patterns or they are uh uh things that they have learned throughout their life, their psychological processes. So when patient have some understanding their own behavior, that how they are unconscious thoughts can impact on their behavior that they can change those things and psychological therapies, it's very interesting. And uh if we, if we can engage people and, and the the effect will long last uh uh rather than medication. So these are very, really good tools. Yes, sir. Now we'll talk a little bit about mental health act and sectioning. Uh Although we can't go into huge details about the Mental Health Act. Uh We thought some pertinent sections are useful for your exams and you've got to have a basic understanding of them. Uh So we have uh just listed some sections here which are used quite commonly. Section two, section two is um a section which we use for admission into a hospital for assessment and treatment that is used usually when we are not very clear about either the diagnosis or we are not clear about the circumstance of the patient and why this diagnosis is presenting in such and such way. That's when we use section two. Section two lasts for about 28 days. Um So any of any mental just coming out of the sections, basic thing about a Mental Health Act assessment is any assessment has to take place in, in the presence of an AMP and two doctors is a social worker who has some extra qualifications in Mental Health Act. So they are important and then two doctors. So three people have to agree that this patient is section and detail and that is when we section them. So coming back to section two, as I said, it's a, it's a section for both assessment and treatment. It lasts only for 28 days after 28 days before the section elapses. You've got to make an assessment again and think about whether they need further sectioning or whether they are safe to be discharged. Uh The next section we are talking about is section three sec. Section three use when we are clear about the diagnosis. Uh And we just, we want them to be detained in a hospital for treatment this last for three months and then this can be renewed. Section three can be renewed any number of times. Uh That's the difference between two and a three and it lasts for uh six months. Yeah, after the first labs, the second time when we done you, the section, it lasts for about six months and then that gets repeated as much as long as we want. Uh The next section is section four, section four is an emergency section and it's an emergency section in the community where the can go and say this person is not safe to be in the community but they are not able to get hold of a doctor or two doctors as the need be. And it is uh it is to put this person in a place of safety I EA hospital ward. Um and then later on plan to have a section two assessment or like a mental Health Act assessment. That's what section four is used for. Yeah, for section two and three that you need uh two doctors who are called section two approve doctors. Hm. But section four, if there is an emergency, they can either use GP or of doctor. Yeah, section 52 and 454. So section five is section for holding. Uh this is not for treatment, not for assessment, this is just for holding someone in, in in the particular place. Most special hospital. Yeah, it's usually the hospital. So what happens is if someone comes by themselves, they are not detained. They are what we call informal patients. They come into the hospital, they try to leave and uh the nurse or the working uh the ward doctor think they are not safe to leave. They want to hold them there. That's when they are used. Section 52 and 5452 is a doctor's holding power. 54 is nurse holding power five to last for 72 hours. Five will last for six hours. So before that lapses, you got to make a decision whether the patient is safe to be discharged or the person needs a mental Health Act assessment and an assessment is arranged, you can't keep people on holding powers internally. Yeah. And after 52, if patient agrees, sometimes they stay as an informal and the 52 is lifted. Yeah, if you want to keep them, but patient is uh arguing that I want to go home. I don't want to stay in the hospital. But if, if you have any concerns, then we need to put them under section two or three. Section 17, section 17 is called section for leave. Basically when someone is on either section two or three or some other forensic sections which we are not talking about now because it's beyond the scope of this lecture and patient is under section in the hospital and they need to go home or go access, access some other facility like another medical facility or they need to go to the council office for some reason, they need to go out of the hospital premises. That's when section 17 is written. Section 17 would have all the rules like this person can go by themselves or this person has to go with two people escorting one person escorting and the leave time is this many hours and the leave is only for this particular place or any other place. The leave is only for hospital grounds or outside hospital grounds or to particular shops. It can be specified. There are a lot of things that can be specified on section 17. The next two, section 135 136. These are sections used by police. Section 135 is used for any private property. 136 is a place of safety like public places. So what happens is if someone is found to be maybe mentally unstable or even they have a suspicion of it and they are on the streets, they're on a, in a shop somewhere where they can be hurt or others can be hurt because of them and it's not safe. That's when police use section 136 to take people from that particular place and place them in a place of safety. Usually the place of safety is what we call a 136 ft in a mental health hospital. But it can also be an and it can also be a police station. It can be basically any place of safety. That's about 100 and 36 for using section 135. We need what we call a warrant. A warrant is issued to the police by a judge so that they can enter a private property. The private property can be the house of a patient. It can be a private office owned by the patient, any private property or even the grounds and the gardens of a house can also be private property depending on the technician. So that's about section 135. As I said, this is a very brief overview. Hope I didn't confuse you a lot with the sessions. Uh That is the reason we didn't put all the forensic sections and every everything else in here because that's beyond the scope of the exam. And also it is not very helpful when you read a number, a number of sections and for you for this particular exam, I think if you know a little bit about these sections, I think that should be fine apart from that, maybe that you will get a question about Mental Capacity Act. Um-hum So better to read about Mental Capacity Act a little bit and Mental Capacity Act. It's uh it's everybody's business. It's not even um medical doctors, even nurses, everybody can do mental capacity. So read about Mental Capacity Act as well. Mm Yeah, we didn't put this here uh because again, we didn't want to overburden you with a lot of slides but please read around Mental Capacity Act and what we call a two stage capacity assessment is very important. Yeah. Yeah. And so we can go through some of the previous questions. Now, I think that's the end of our slide presentation. But if you want to ask questions, you can ask um otherwise we can just practice from few previous uh exam questions is up to you. We are happy with a a are there any questions in the chart or anything anywhere? So how do I stop sharing? Can you heavy? Yeah, sorry. I was just struck on the microphone if there are any questions in the chat at the moment. Um But we have uh a lot of people saying thank you. Ah OK. Yeah, you're welcome. We are happy to do either way we have seven minutes. It's up to the candidates basically how they want to use that time. We can go through the questions if they want or we can just let them go. Um Yeah, the I'll just see there's still about 30 people here. So if there's anything additional to add Oh, wait, hold on. We got uh can we see some questions we have someone asking for questions? Uh OK. So I will read that one question. Which class of the drug have medicines and healthcare products, regulatory agents you want may be associated with increased risk of uh venous thrombo thromboembolism in elderly patients. So they are asking about the is which medication can cause? VT uh Examples are uh questions are tricyclic antidepressants, five HT three antagonist, third generation cephalosporins, benzodiazepines, atypical antipsychotics. So I know it's difficult to understand the question when we are reading out instead of you having it on the chat screen, we weren't really sure how much time would be left and how many questions you would have. So we didn't make slides for them. So basically, the question asked M HRA has warned us about VD risk in elderly, about a particular class of an, a particular class of medication. And the options we have are T CS or five HT three I antagonist that is are SSRI s third generation cephalosporins, antibiotics, benzodiazepines and atypical antipsychotics. Now, in our slides, we don't directly have the dance. But how would we get there? The I'll give you the correct answer. The correct answer is atypical antipsychotics. But how do I get there? Because that's the only one that says metabolic syndrome. So, metabolic syndrome is increase of fat, increase of um like diabetogenic kind of um situation in the um atmosphere in the body and that we, we get to it indirectly because we can't really read about all the side effects of all the medication. That's how we go through it and that's how we get to the answer. Another question. A 65 year old female with history of ischemic heart disease is noted to be depressed following a recent m what would be the most appropriate antidepressants to start? Now, I don't want um, Ira to read the options. Yeah, because I this was given, this was given in the slides. We talked about this medication which we would give after an ischemic event, heart disease, some antidepressant which is safe after heart disease. Can anyone give an answer while you are thinking that people with heart disease, they are at risk of developing mood disorders? Someone says certainly, yeah. Good, good. Right. Yeah. So people with heart disease, they are at risk of developing depression. People with depression are at risk of uh developing heart disease. It's, it's both, it goes both ways. So according to trial called me, uh that sad heart trial that certainly needs the safest antidepressants and tricyclic. We are a bit cautious because of the QTC prolongation, right? Uh Another question, you are a junior doctor working in the A&E department. A 56 year old man is brought uh in by his wife. He looks unwell and sweating profusely. He tells you he has abruptly abruptly stopped drinking alcohol and used to drink heavily. So you suspect he may be withdrawing from alcohol, which neurotransmitter mechanism causes alcohol withdrawal. Can you type the answer again? We talked about the mechanism of action of alcohol. Yeah. So if you are withdrawing from alcohol, the reverse happens. So what did we say? What neurotransmitter increases and what neurotransmitter decreases in alcohol consumption? Again, that, um, alcohol withdrawal and opioid withdrawal, that opioid withdrawal is very, very, um, uh life threatening. Uh alcohol withdrawal is life threatening but symptomatically that people with opioid withdrawal, they have very severe symptoms. But alcohol withdrawal can. Ok. If someone says glutamate increases with withdrawal, very good. Something something decreases. What decreases glutamate but does it? Ok. Yeah. Yeah. Yeah. Yeah. Good. So alcohol decrease. Um So making some of this is making some affection. No, no. Um So gaba is increased and glutamine is decreased in mechanism. Yeah, reverse happens in VRE Yeah, that's brilliant. So another question. Uh a 35 year old female present to the emergency department following a deliberate paracetamol overdose. Which one of the following feature is most indicative of uh continuing high risk of suicide? I think again that we did not touch uh that risk risk assessment. This is another important aspect in psychiatry people. When somebody is coming with suicidal idea, we need to assess the risk and uh think about management plan accordingly. Whether this patient need to come to hospital or whether the we can manage this patient with the use of crisis team or whether we can send this patient home. Right? So the question is which one of the following that, that according to today's that uh that rule, what is the most risk that that this paper patient will do similar thing again, right? Staggered overdosed, mixed overdose involving other drugs. Female gender may the first to avoid herself being found by a friend and family consume 50 g of paracetamol. So these are five options. Uh What is the high, what is indicative of the highest risk? Is it staggered overdose? Is it mixed overdose with other drugs or is it being of female gender or is it that they have made efforts not to be found by anybody after they took the overdose or is it about the amount of paracetamol? Oh yeah. Oh yeah. Good. Yeah. Avoidance of discovery. Yeah. Yeah. Yeah, good. So when risk assessment that if somebody has uh taken serious overdose with planning, if somebody has written suicidal notes and if they have done certain things not to be found by others uh and previous history of self harm. Uh male gender, older people and people who have some contacts with health care professionals, they are, these are the high risk categories now. Yeah. What is substance? Yeah. All having substance history, history of substance abuse. So it it really pays if um we can go through risk history. As I said, it was quite difficult to decide which ones do we sell to put in, into our less than 20 slides. So, yeah, risk history. Intent is very important, whether it's suicide or self harm, it's about the intent. Severity is also important. But intent is more important, especially that eu eu PD patients, they say that I cut myself not to kill myself, but this is how I cope. So their intent is different but sometimes people with depression, they just, they can't see future, they just want to end their life. So they are at high risk. One next one. It's quite long question. A 27 year old woman present to the GP with a low mood related to her loneliness. She explained that she has always been shy and describes intense fear of others judging or rejecting her for her inadequacies. As such. She has avoided close relationships and stopped seeing the few friends. She did have these fears affect all aspects of her life. She chooses to work in a solitary job, has solo hobbies and has never had a relationship. Her difficulties with social situation mean that she keeps to the same limited daily routine, although feels unsatisfied with this. What is the likely diagnosis? So the options are ast autism spectrum disorder, avoidant personality disorder, generalized anxiety disorder, schizoid personality disorder and social anxiety disorder. Someone who has been shy, always someone who is always worried about how people would judge them and also they are missing it. They want friends. They want to have a social circle but they are, they are lonely but they can't get out because of these fears and, and she's unsatisfied with this. Yeah, she wanted to have friends but she is not able to but she is not able to. So the options are autistic spectrum disorder, avoidant personality disorder, generalized anxiety disorder, schizoid personality disorder and social anxiety disorder. Someone had social anxiety. Ok. Let's see if there are other choices. So uh I would say why it is not social anxiety? I don't want to give the answer out. She has been shy from early early life. She has been shy, shy since childhood. Always been shy. That's what the question describes. So it has not be, it has not started after a key event or it hasn't started later on in life. That has been part of her since she was young, part of your character since young. I'm, I'm trying not to use the word. Yeah. Yeah. Yeah. And that social anxiety I think II think we when you have this kind of question, think about main symptoms of each category and then rule out. Yeah. No. So two people have said avoidant PD, avoidant PD is the right answer because this has been a part of her personality. That is why it's a personality disorder. It's not a disease. A generalized anxiety is a disease. Social anxiety is a disease which is countered, this is a personality disorder why is it Personality disorder? Not asd because she wants that contact. She is feeling that loneliness. She is not just happy in herself. Autistic is that they are not aware of other people's, um, feeling so they're not aware, they, they don't even want that kind of social connection, but she wants it. So that's why it's not autistic. Yeah. Yeah. Do we have any more? We have one more. I know we have five minutes over. We are happy to do, do that one more. Yeah. Nice. Yeah, you can wait that you are seeing a 46 year old man during a GP placement who has a history of depression. He recently separated from his partner and on questioning admits plans to take an overdose. He has never done this previously and says that he doesn't want to because of the heart it would cause to his mother, but that he cannot see any other option. He has the tablets at home that he plans to take. He denies alcohol or drug abuse in this situation. So the situation is that he wants to die. He, he does not find any point in living, but he thinks about the hurt it would cause to his mother, not because he has some hopes of future but because of the hurt it causes to his mother. So what do you do in such case? Send the patient to the emergency department as it is a safe place? That's one option. Speak to the crisis team, speak to the CAM S team, cam S child and a adult and mental health team. Try and speak to the patient's partner to encourage reconciliation. Ask the patient to come back and see you the next day. So these are the five options. You send them to Ed, you send them, you speak to speak about them to the crisis. You speak to the CAM S team or you speak to the partner to try and if they can reconcile or you ask the patient to go home and come back the next day, what would you do? Yeah, that the, that's why that at the first slide that we, we, we mention that, you know, it is important to think about setting and that scenario because one answer should not, you know, apply to the other scenario. That's why it's very important. So OK, so two people say crisis team, that's good. Uh It would be the crisis. We are not sending the patient to Ed because by nature, uh by the time they are assessed by the Ed, they might be about one not to us. Also, you're sending the patient, you're not with the patient. Um Of course, it's not your job to reconcile between a strange partners. No, that's not in your job description. So you wouldn't do it. Cams is a total non secretor. The patient is 46 year old. Why would you speak to CAMS? And then ask the patient to go home and come back. No, no, you can't do that because the patient, he is suicidal. He, he has quite strong intent. So yeah, crisis is the correct one because they, but, but in a different scenario, maybe that same question that if you feel that because crisis that they, they will support you at home, but they can't supervise the patient 24 7. Hm. So if there is a risk that crisis team can't hold or keep that patient safe at home, um you may consider uh admission then that, that come to the A&E that uh then that then the A&E that mental health liaison that uh they there are a liaison team that who can see this patient assess the risk properly and maybe that this patient will need admission depending on his intent uh and the risk. Yeah. Yeah. So always consider your safety, patient safety and the setting answers change. But yeah. Yeah. Uh do we have any more? We have more questions? What about how do you, how do you feel should we continue? We have about three or four more questions do you want or do you want to finish now? I know you had a long day but we are happy to go through them if you want no answer. I think they, they are. No, no, that's ok. Right. Yeah. Ok. Oh, more please. Someone says more. Ok, fine. Ok. Yeah. Yeah, you can read PNA. So the next question is you review a 17 year old man, 17, 17 with a history of anxiety and depression. He is under the care of child and adults and mental health service who have recommended the prescription of an SSRI. What is the most appropriate drug to prescribe? We haven't covered this bit in SSRI, as I said, we uh we can't cover everything. We haven't covered this. But let's see if someone can answer this. So the SSR Oh, that's good. You are too fast. Yes. Yes. It's FLUoxetine. So, FLUoxetine is the drug which we give and it is also the most preferred drug in um premenstrual tension. That's premenstrual dysphoric disorder. We call when people have premenstrual mental symptoms which disappear once menstruation appears. That's when we give FLUoxetine. Yeah, it's the necessary of choice in Children. Yeah. Well done. Rebecca next one. A 60 year old man with chronic schizophrenia presented with nausea and vomiting, nausea and vomiting wise is important. Have a think about it. He receives metoclopramide for his symptoms. 20 minutes later, he becomes agitated and develops marked oculogyric crisis and oral mandy blood dystonia. Yeah. What is the answer for dystonia? What is the treatment? I think Praveen mentioned. Yeah. Uh So the options are give him haloperidol LORazepam, midazolam, procyclin procyclidine, propofol procyclidine. Yes. Yes. So the important learning point here in this question that we mention extra pyramidal side effects with um antipsychotics. But apart from antipsychotics. Other medication can also cause extra pediment side effects. For example, metoclopramide, it's a commonly used drug for nausea and vomiting. So it also uh acts on same receptors. So that's why it also can cause dystonia. This is a very distressing and uh uh severe side effects that people can develop respiratory depression as well. So it is important to treat this. So medication is procyclidine, procyclidine is can be given both im and oral. So that's something to to be aware of. Yeah, in psychiatry, when patients develop extra pimet side effects, we think other things like reducing the medication, the reducing the dose or splitting the dose or considering switching it to second generation antipsychotics. These are the other management options rather than adding procyclidine. Sometimes we add procyclidine but sometimes it also cause uh intolerable side effects to some patients. Yeah. Yeah. A 72 year old man with a background of seizure affective disorder is reviewed by a psychiatrist in the community. After family members reported worsening affective symptoms. The patient's daughter reports that he has stopped eating entirely and has made strange comments about death on examination. The patient speaks with a quiet voice and does not make eye contact when directly questioned on the cha change in eating pattern. The patient says, why would I need to eat? I'm already dead. Corpses have no need for food. What psychiatric phenomenon is most consistent with the patient's presentation. Capgras syndrome. Charles Bonnet syndrome, Cotard syndrome, erotomania. Now, this is another thing we didn't cover. Yeah, there are famous syndromes. Cotard, very good Cotard syndrome is when people think that they are already dead. Cotard, most common with older age patients uh with this theme that uh they, that they are there, that nihilism, those kind of things we can go through other syndromes. Probably not that ery. Do you know about eto, can anyone tell us what Erotomania is? I don't think so. Yeah. Yeah, you go ahead. So eto mania is when people think that they a famous person, uh delusion of law. Yeah, typically with a famous personality. Yeah, someone like a celebrity. Yeah. Charles Bonnet. Does any do, does anyone want to say what's Charles Bonnet syndrome? This is again common with patients with old, older, older people, Charles Bonnet that when somebody has problems with vision uh and then they can present with um psychotic symptoms, delusions uh that is charge burning Capgras Capgras syndrome. Capgras syndrome is when they think that the family member, some family member or pet, someone very close to them has been displaced. They, they are not that person, they are someone else that is Capgras Syndrome. Yeah. Sectioning under the Mental Health Act. Um So which section allows admission for treatment for up to six months? Yeah, up to six months. What is the number? Which section we have talked about it? Section 2345. Yes, se section three. Well, done. Yeah, good. Which section allows someone to be taken from a public place to the emergency department, public place to emergency department by the police. Yeah, place of safe safety. Basically that they are asking 136 good um 72 hour assessment order for a patient who is not in hospital, patient is not in hospital emergency section for 72 hours. Oh, this is a good question. We didn't mention 72 hours. So let's see if Yeah. Yeah. So somebody, yes, so good. Somebody, if somebody is not in hospital that we can we we have to use section four. If somebody is in the mental health hospital, then we can use section 52. Yeah, 54 or 5254 is for nurses, nurses 55 72 hours. Uh 54, only six hours, six hours. Yeah. Yeah. A 25 year old female presents to the emergency department with eye pain and then abnormal posture on examination. Her neck is fixed up backwards and laterally and her eyes are deviated upwards. She is unable to control her gaze. She has recently been diagnosed with paranoid schizophrenia and has been prescribed OLANZapine. That's a red herring there. So what is the most likely cause for her symptoms? Achatia, tardo dyskinesia, parkinsonism, acute dystonia catatonia, eye pain, fixed neck backwards and laterally neck is fixed like that. Yeah, and then eyes are deviated upwards and she has no control on the eye movements. That's why again, be familiarize yourself with this E PSE P SAS. Uh it's an acute dystonic reaction. The red herring here is OLANZapine. When you see OLANZapine, you think it's OK, it's second generation. Uh so it can't be that. But the answer is acute dystonic reaction because of all the symptoms. Yeah. Someone said catatonia. Yeah, Catalonia is a different one when somebody is catatonic that they usually don't talk, they are mute and no much changing in post interaction with people. Yeah. People can present with catatonia when they are severely depressed. Sometimes very psychotic patients. Yeah. Yeah. So the way I did, I remember catatonia is when I was an F two. That is how I remember. I don't know if this helps you. It's like the definition of inertia in physics. I know I'm a bit geeky but um uh it is the state of rest or uniform motion of something of a thing that's inertia. Same thing with catatonia. They are either doing the same thing over and over without active acute intent or they are not doing anything. Both are catatonia. So when we think of catatonia, sometimes we just think of people sitting like this like a doll, not moving but doing the same thing over and over can also be catatonia. So that's how I remember it. It's like in, it's either the state of rest or of uniform motion treatment. Basically catatonia, we give high dose of benzodiazepine sometimes people do get better but extreme Catalonia sometimes we use ECT um we, we did not mention about ECT this is electro convulsive therapy. So when patients are severely depressed life threating, then when they are refusing to take any oral medication or if somebody is not uh responding to oral antidepressants, we give what we call electroconvulsive therapy, we give some shock under anesthesia, then people do get better. Is that enough? Now, is this the last one that we have more? We have more? Maybe we can send them is, yeah. So we are actually 20 minutes over the clock. Yeah, I think we'll stop here. Uh, and they read little bit about depo medication as well because mentally ill patients, sometimes they, um, they ha they don't have inside, they don't think that they need to take medication. So then they present with relapse. So to manage these patients, we use depo medication. So we give, uh, antipsychotic as an injection every two week, every three week or monthly. Where are these questions? These are from the old papers? Old MSR papers. Yeah. Um, I think the organizer shared with us just to get an idea the, to know the level of the exam. Yeah. Yeah. Uh, I hope this was useful. We could go on and on, but I don't think that, uh, we are already 20 minutes over the clock. So I think we'll stop here all the best and good luck. Yeah. Please read through the topics. Like when we mentioned one slide, please be there on that topic that would help and uh consider psychiatry. And this is a very good specialty. Are nice people. Yeah, you have a very good family life and work life and you know, we are very helpful. So consider psychiatry chose psychiatry, not, not even consider, choose a psych. Bye. Thank you. Bye. Thank you so much for excellent talk. Um Thank you everyone very much for attending. Please me to fill the feedback. Um We've also released the med feedback for the day. Um So that should be there available for you. Um So you should be able to see that. Ok. Thank you so much. Just take us off life.