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Overall, I'd say psychiatry is actually quite a low yield topic for exams. But on the flip side, there's very, very little you actually need to know. Um So in that sense, it could be considered high yield. Uh It depends what your revision strategy is. Uh But yeah, so uh those are the question counts and the things that are most likely to come up question one. So he's old is hospital. Uh He has confusion. Uh There are some psychotic features, okay. I think there are uh 88 people here. Um So take 75. So both people pick C which is correct. A few people picked B and E. Uh So let's go through why? Those are not correct. Um So first of the thump, uh he has alternating confusion, very important, alternating confusion with periods of lethargy. When you see that line, you should automatically already ignore anything that is not delirium because although little body does have fluctuating confusion, uh doesn't have fluctuation with market lethargy. So this patient is fluctuating between hyperactive delirium and hyperactive delirium. So you can almost automatically ignore A B D E already. Um That light alone is already delirium. And then obviously, you've got other dilemma, risk factors there. He's in hospital chest infection. He has episodic confusion. Uh And then the psychotic features you can get that way to Lear um as well and even give you the, the um vital signs which shows that he is basically having a fever right now. It's 10 to 37.8 as pulse is 100. So that's why the most likely answer here is see um then dementia doesn't fluctuate that fast as a not within the single, not within a single day. Um uh Then bipolar doesn't have any mood symptoms, the anxiety aggression, that is agitation, not elevated mood. Uh Nobody was supposed about schizophrenia. Um Schizophrenia is late onset schizophrenia. So, you know, after age 20 is actually quite rare. Uh it's very unlikely a 73 year old man is suddenly developing uh schizophrenia, right? Uh So what is delirium delirium is, I mean, is not gonna spend too much time on this, just a minimum amount you need to know for exams. Delirium is basically brain failure. It's total brain failure of all brain domains. So D S M five has these five key criteria. Uh The key is it's attention awareness, it develops, have a short period of time and you can prove this by speaking to the family collateral history, etcetera. It fluctuates during the day, very important and that you have ruled out some other basic causes and delirium is always secondary to an acute medical issue. So additional features um in the hyperactive state, you can get the, you can get, you know, high heart rate, hyper pressure, sweating, etcetera, and hyperactive state. The patient will basically just be in bed looking like they're completely uh frozen or even sleeping. And the risk factors of delirium. If you have an unhealthy brain, those previous dementia, previous stroke, Parkinson disease, um alcohol abuse, anything like that, you're more likely to get delirium. Uh Basically, it's just like if you have see if you have chronic in to see if you're more likely to get acute kidney injury, you have pre existing heart failure, you're more likely together. Am I uh if you have pre existing brain failure, chronic brain failure, dementia, you're more likely to get acute brain failure, acute and chronic is delirium. Okay. So, cause delirium. Uh common, common slide where they put like 20 different causes. It doesn't matter. The point is delirium is simply any acute medical issue in cause delirium and drugs, paying constipation, your retention. Um and right metal change, that's it. Any, any accu medical issue that upsets the brain, the brain doesn't like kind of think that kind of physiological stress uh cause delirium. Uh So, subtypes delirium. Uh this patient demonstrates both, you get hyperactive delirium with meditation and aggression and you get hypoactive delirium, which basically patient is commonly um labeled as sleeping or drowsy or not engaging whether in fact, there actually in a state of disordered consciousness, they're not actually sleeping. If you try to open their eyes, they resist because they are conscious, but their brain is not functioning. That's why they have no uh limited awareness of their, of things happening outside of them. And flip flopping between the two types is very common and almost passed economic for the barium. Uh And then another pro tip visual hallucinations are almost always organic, almost always. It's quite actually rare to get um fully formed visual hallucinations in primary psychotic disorders or bipolar. Sometimes you can see like weird illusions first things but very well. Did he get proper like animals or people full on visual hallucinations? Um Sundowning again is very classic. So in this question, the patient actually does say uh it's more pronounced during the evening, the period of market liturgy. So that points more towards delirium as well. And the reasoning is supposed to be that it's dark. So it's more likely to um have um missing illusions which are misinterpretation of normal stimuli. Um as well as the sleep wake cycle is disrupted and reverse delirium. So patient awake all night sleeping during the day or rather, again, not truly sleeping, they're hyperactive at night and they're hyperactive during the day. And here's how to um differentiate between delirium or dementia for I think one person chose um uh meant to. So the key is in the timeframe and the and the the nature and the speed of the fluctuations. And then also, unless in a very late stage dementia does not cause an impairment of consciousness. Um That's specifically a delirium thing. Any questions from chat? I got our feedback that says last time says, please engage more with chat. So before I move on to the next section, no questions. Okay. Uh Yes. So there's a few caveats, their vascular dementia which will go through Demory vascular dementia, slowly progressive. Sorry, basket dementia is step wise progression first has Alzheimer's which is slowly progressive. But then of course, in real life, sometimes you see the family saying, oh, you know, my mom was completely fine at home and then she wanted to hospital with U T R and now she's totally demented and the reason that is is because they had probably underlying dementia uh mild as we said, unhealthy brain risk factor, chronic brain failure, risk factor for acute brain failure. And then they get hit with delirium and they get acceleration of the dementia just like every AKI you get in CKD, makes your kidney function uh deteriorate faster every episode. Delirium in dementia progresses your dementia faster. Okay. Another one uh the 66 year old uh forgetful, poor sleep loss of appetite. Uh She has been getting up early in the morning or MSC is uh 27. Remember this is an exam question. This is not real life. We're trying to determine if they have uh some form of dementia where they have good MMSC but bad other things, this is purely an exam scenario. They're not expecting you to be a diagnosis. Asian. It's good. Everybody picked. Yep. Great. Everybody picked depression. Very good. The answer is depression because her MMSC is normal. Again, it's an exam question. Fine. Another one 79 year old, basically the collective employment impairment. Um The question stent doesn't actually help you. Um figure out what the answer is. This is a pure fact recall question. So based on the history, she has the media, um probably Alzheimer's. Um So the question is just asking uh Alzheimer's dementia, which aspect clinician shows the earliest impairment. So you don't know what practice means. Don't worry, I didn't know as well. That's why I didn't pick that answer. Oh Interesting. Uh Two more people left to answer. Okay. So the answer is the short term memory, by the way, practice is the ability to do skilled movements. So that's what the it's part of what the shape drawing stuff in. Uh Boca MMSC is testing. The answer is short term memory and Alzheimer short term memory is the earliest cognition impaired. So Alzheimer's uh they have a lot of questions this. So let's just go through it carefully. Um It's primarily a problem memory impairment. And importantly, it is initially it's a degeneration of the hippocampus and medial temporal lobe. And that is why those specific functions so short term memory and episodic memory, especially for recent events. Those are the ones that are affected. First, later you get global brain atrophy. Um So it's only later that you get your non hippocampal and subcortical and prefrontal uh memory functions affected. So that's your procedural memory, long term memory, vocabulary and concepts. Um So the whole um technically speaking, the long term memory can also include forgetting words, you just memorized um during the MMSC of the mocha. Um But the important part is just Alzheimer's is hippocampus, a meal, temporal lobe. Uh first generation, which means short term memory goes first and later on, of course, you get the executive function, the frontal lobe generation. So you get your organization and low motivation, apathetic states very commonly misdiagnosed as dementia effect. Um It may be worth just treating the patient empirically as depression because it's quite difficult to differentiate between the two um in Alzheimer's and then you got the visual spatial impairment. So that's where the uh you've seen the moca test the drawing A three D three D Q that's really special as well as draw in MMSC drawing the intersecting pentagons, that's also a visual spatial and then you get a whole category of um emotional behavioral symptoms. Um Most commonly abbreviated as BPS D um usually appear in middle and late and that's where you get um apathy, irritability and then um clip second article, agitation and wandering. So another it's wondering is actually a middle to late sign of Alzheimer's already. So let's just do uh compare the scans in these diseases to sort of drive home the differences. So an Alzheimer's dementia again, initially get meat on temporal lobe hippocampus, but eventually you get total cerebral atrophy. So you can see you've got very deep uh sulky full of fluid, um full of CSF and you get very big ventricles because all these white matter here shock. uh we're going to a vascular dementia. Uh This is actually MRI not CT but all this white stuff is a very large burden of small vessel disease. So just like you can get uh sclerosis or peripheral vascular disease, you can get that in the bread. And that is what vascular menta is. Vascular dementia is essentially the accumulative effect of numerous micro strokes and cerebral ischemia, a little body dementia. Um Of course, the classic thing is it's Louie bodies. Uh you get the whole problem with psychosis uh and neuroleptic sensitivity and Parkinson your features. And the reason is uh but unlike Alzheimer's, they actually don't have as much problem too short term memory early on. And the reason is the circles are looking at the medial temporal lobe, as you can see in Alzheimer's very generated in Lewy body dementia relatively spared eventually, that will also go. And you can also look at the ventricular volume as well. It's a little bit better and everybody uh than Alzheimer's. So the other exams, types of exam, types of maintaining to memorize. So, vascular menta, you're looking for a stepwise progression, um history of strokes or post strokes and early on it's executive function processing speed um that gets stroked out, but it does depend if they have a massive frontal lobe stroke, then you're gonna get frontal, a more frontal uh type of dementia. Uh everybody dimension. That's the one which is an overlap syndrome with Parkinson's and psychosis. So you get visual hallucinations, you get fracturing confusion brackets has to be proven to send delirium first and then the class exam question and just never ever ever give antipsychotics. Somebody will do about dementia because of the whole dome a dopamine related problem. They are very sensitive to antipsychotics. And then last, you've got frontotemporal dementia. Uh There's actually two subtypes, there's a behavioral one and a a phasic one which is what uh Bruce Willis has. But essentially what you get is you get frontal lobe degeneration, which means disinhibition, um apathy uh behaviors. It's very behavioural syndrome. Unless they get the um uh the a physics subtype which is then they have problems with the speech early on. Here's a nice summary table just to uh summarize all of what we've spoken about. Answer the question from chat in a second. The key is in the type of progression and the key features. So uh just based on the history, you can, at the very least you'll be able to rule out Lewy body and leaves you a vascular and Alzheimer's and then hopefully, the his his questions, then we'll give you a bit more subject to tilt you between one or the other. Uh And then you will be able to figure it out from the question. Uh Can I have permanent effects? Sorry, which, which one is just referring to um delirium a day earlier? Um So that's another interesting question. So generally speaking, um most definition of delirium say it can last for up to three months. Uh And then after after three months, 3 to 6 months, actually, and after six months, if the cognitive impairment is still persistent, then the patient can be officially diagnosed with dementia or at least cognitive impairment. Um Again, most likely what's happening is have mild dementia already. And then the delirium has merely accelerated it, healthy brains very rarely get delirium unless they're critically unwell, essentially would not get the Lyrica just a mild uti or something like that. And then of course, the lithium itself has very, very poor prognosis, um huge increased mortality, way cognitive impairment rate, etcetera, etcetera. Uh There's actually a great stat. Um there's a small study done for post neck of femur fracture. Patient's uh the ones who got um uh post operative delirium. Uh 69% of them end up having dementia eventually because again, they had dementia to start with. Probably just nobody noticed because they were at home uh fell and then the anesthetic drugs triggered delirium in the operating state and then turns out actually they had an unhealthy brain to start with. But yes, it's true that proper delirium with no underlying dementia theoretically or cognitive impairment should resolve. Um That's one of the definite that the definitions of clear. Um, or at the very least the patient should go back to their baseline unless they're dementia is being accelerated. And most often you do find that the online dementia gets accelerated. Uh, moving on. So, trigger warning, uh, we're gonna cover presented disorders, various medications. Many of you may have percent disorders yourself or medications yourself. Um, I'm going to speak without them in a very reductionist, oversimplified. Possibly even, uh, like not representative meaning way. That's only because helping you revise for exams. I don't actually think like, uh, people with present disorders like that. Right? Ok. So question 18 from 82 introverted, uh, 17 year old. If you have already chosen your answer, there is a major typo in this question. Um, uh, so I've copied, pasted it. There's a major typo in the question which, um, nobody has noticed for three years if you can spot it. Um, good on you. Mm. Interesting. People are, it's a good thing. I, uh, I was originally planning not spending too much time personally, disorders but looking at the, uh, answers spread. Oh, dear. Uh, sorry. There's, uh, there's, uh, keep looking for that. Typo can answer the question from chat with regards to Lewy body dementia. How does one differentiate compared to Parkinson's, which is the previous answer, the motor symptoms. So Parkinson's should have less uh less uh fluctuates confusion and less visual hallucinations pockets sends the motor symptoms are more prominent and you only get Parkinson's later, dementia uh later uh but very much there in the, just on the spectrum of Lewy body disorders, they're all in one spectrum. And obviously, if you get a pocket size plus syndrome, then that helps a lot as well. Yeah, basically there's an even split uh answers. Although slightly more people picked a which is congratulations. The answer is avoidant personality disorder and the major type of was the age, you can't diagnose personality disorders before age 18. Because psychologists and psychologists think 17 year olds don't have a personality. That's just the rules. You could be 17.9 years old and your branded as your personality is not developed yet, not fully fixed. Therefore, you can't have a percentage disorder. You can have conduct disorder and then as soon as you hit age 18, boom, your personality is flicks, your life is life, your personality is fixed, your life will be like that and you can officially be diagnosed with a personality disorder. Uh So that's the major type of their, they should have made it aged 18, not 17, um key words. So presenting this other questions in general, all you have, it's basically, it's simply just a reading comprehension exercise. You don't need to know anything about the underlying pathology or the treatment. You just need to pick up the key words and match them to the, the correct answer. So for her, she refused to attend party, she's worried about criticism. She sends the rejection that is avoided percent disorder automatically done. Uh doesn't match any of the other features. Okay. Another one, 25 year old overdose fluctuating mood. Actually, I think a psychologist psychiatrist would say effective instability. Okay. So most people have picked use correct. This is a classic symptoms of um emotions, stable person's order, borderline subtype. Um A few people picked a and be so ah so it can really be adjustment disorder because uh it's persistent at the patient is 25 years old and adjustment disorder does not really cause the uh random mood the the excessive rapid mood flipping bipolar disorder. So you have followed into the classic trap. People think bipolar disorder means wild mood swings. It doesn't. So bipolar disorder, mood fluctuation from um low, too high. It takes a while usually on the order of days, two weeks. Uh it does not fluctuate several times per day that is emotionally unstable personality disorder. Uh you very often you find patient's have been labeled with um bipolar disorder on their psychiatry notes. Um even though they have emotion sale person disorder, largely because there's very little funding for U P D treatment services, but there's more funding for bipolar disorder. Uh but bipolar disorder mood fluctuates so they don't fluctuate multiple times per day. That is, that's never going to happen in bipolar disorder. And of course, emotional Sale Person disorder, you give them mood stabilizers. Uh doesn't really help because it's a percentage disorder. There's no organic or there is but there's less of an organic basis. Okay. So uh the key features he has every single classic feature of emotion sale percent. Yours are borderline subtype is got uh multiple mood fluctuations in a, in a day, possibly even uh on a weekly basis, positive even on a daily basis. Uh Sorry, one more feature which I'll explain later is that the mood fluctuations are environmental. They happened after uh he had an argument with a friend whereas bipolar disorder uh doesn't have to be an environmental trigger um or they could have just stopped their meds unintentionally and that that will trigger a relapse. Okay. So, uh the key diagnostic criteria for or rather how separate preside disorders from mere traits because there are people who are have chaotic lifestyles but don't have a personal disorder. So the problem has to be pervasive. It affects almost all as through life has to be persistent. So, although you can't diagnose it officially before age 18, they should have some evidence um of issues before age 18. And certainly, um again, classically in emotional presented or there's almost always a history of childhood or adolescent sexual abuse. Uh And then uh there has to be pathological. In other words, there's a serious disruption to uh their self for others. So again, an emotion salesperson disorder, although they make many suicide attempts, um very few of them, very few of which have true intended in their life. Um Eventually they will accidentally three misadventure calls, serious harms themselves have seen patient have bilateral leg amputations because uh one of the times they uh lied on the train tracks that one time they were actually run over by the train, but he did not have depression or schizophrenia. He just had emotion Silverstein disorder and it's just one of numerous times he had made a suicide attempt without an attempt to kill himself. Okay. So the I C T 10 sets out the quote report criteria which um is um anomic they invented to cover these um six features. Um The slight overlap with the three piece there. Um Any questions on that before we move to next slide. So the difference between traits and disorder is it has to be so bad that it's causing serious impact on their life and has to be affecting everything. Uh It can't be turned off because it's their personality, okay. Uh So hopefully a psychiatrist has taught you the diagnostic Harkey properly. Uh But the other problem is um again, people who have accidentally chosen bipolar uh sort of U P D in the previous question, the there is a diagnostic pyramid in psychiatry, uh percent disorders at the bottom of the pyramid and everything else, everything else goes above. Um So in order to be sure it's a percent disorder, you have to be sure it's not one of the higher order disorders. So that's kind of compulsive disorder, personality disorder. They have obsessions. Uh I don't really have compulsions. Uh Repetitive behaviors are not, it's not like uh true OCD in which the rituals, they don't do the rituals, they have severe distress. Uh That's not the case. Uh You know, sense of capacity percentage order, repetitive behaviors are not directly related to obsessions. Uh in schizotypal percentage order. Uh They have sometimes they are aware of the magical thinking. For example, they might say, ha ha you might think that sounds crazy. Um Unlike a person suffering with some stuff Renea schizophrenia, they are essentially existing with different plane existence from you. It's like arguing with somebody with a different political view. You will never be able to argue them out of it because they are true believers in there um in their delusion. Uh And then the perceptual disturbances in schizotypal percent is sort of, for example, seeing halos around people um thinking it's some kind of religious, religious experience. Um It's not a true hallucination as in they know it's not super, it's not exactly real. Um It's not like out of nowhere that makes any sense whereas, and they very barely hear true voices. Whereas of course, in schizophrenia, they will hear actual voices and classically the voices are here, uh just behind their ear. Then we discussed the Russian table percentage order already. And then you'll see this in psychiatry inpatient that if the patient's ever had medications before being sectioned in the patient's ever had medications before being section, you can't diagnose uh schizophrenia or anything like that. You have to wait for the drug to wash out because of the diagnostic hierarchy. So very often you'll see the patient's being labeled as uh I see decodes F 10 to 19 mentally behavior disorder, secondary to substance abuse. And on the second admission where I didn't have any weed, then they can get diagnosed as schizophrenia. All right. So uh the person disorders are categorized into clusters. I promise there will be no pictures um uh person disorders after this because those are very demeaning. Um Those are the clusters cluster. A is termed the odd and eccentric cluster cluster. Be is dramatic and erratic and cluster. See is the anxiety and fear um disorders, right? So again, all you have to do for personal disorders is to memorize these key features and then look in the question, pick up the key words and choose the right answer the MCQ. You don't need to understand anything about the treat. With the exception of U P D, you need to understand anything about the treatment or the background or anything like that. Um So uh I take no credit for these genomics. They're all from an excellent book called Psychiatric PRN, which I'll put in the end. So, a Paranoid Percent Disorder, um it's basically suspicious of everybody and having conspiracy theories. Um The differential is schizophrenia and delusional disorder. But um of course, they will have multiple of these conspiracy theories. So it can't really be delusional disorder, schizoid personality disorder. Um As a not there's an economic um these patient's or these people prefer to be alone, daydreaming, uh not really participate in normal social conventions. Uh Differential includes Asperger's syndrome and the various social phobias. Uh 50 to put questions in the chat, we'll go through these present disorders quite quickly because there's nothing to do for the other than to memorize the features histrionic presented disorder. Um uh usually it's quite obvious from the questions them um innovatively, um it's female, partly because of stereotypes and probably because uh female patient people have a higher risk factor, higher uh theology for histrionic percent disorder versus mail. Essentially, this is the one which is attention seeking and races seductive. The the other present disorders don't have being raised in selective as a key feature, not even emotionally symbol present surgery, right? So I've only covering the borderline subtype, not the impulsive subtype here because I think the impulsive subtype very rarely comes up in questions. It's probably going to be the borderline subtype. So there's two criteria steps. This first is the general A U P D criteria which are effective, instability, um explosive, impulsive behavior, anger outbursts and the inability to plan across the consequence. Then a subtype for the borderline sub criteria, uh it's turned borderline because it's borderline for psychosis or borderline for bipolar. Um They have the chronic emptiness and a band mint and relationship issues. And all of these manifests as suicide attempts and self harm as both as a coping mechanisms and also as a distraction from there. Um chaotic and, and, and sad life basically. So in this question stem, we've got a classic example of splitting, which is when people with U P D tend to um think of things very black and white, either you are against them or with them, either you're the best lecturer or the worst lecturer. Uh and then a single event or a single thing um that goes against that will make them flip on you. I hate you forever. So that's a classic uh borderline percentage disorder sign. Yes. Differential includes adjustment disorder um or, and connect disorder, but of course, it's age related and then also adjustment disorder doesn't really have the um suicide attempts. Uh So again, because it's bordered I for psychosis, um you can get studio hallucinations, many patient's report um hearing, for example, people in the street criticizing them. Um those are terms to do hallucinations because they don't reach the threshold of real hallucinations which actual patient psychosis have the treatment you do need to know uh is dialectical behavioral therapy there, of course, multiple kind of psychotherapy for U P D. But DBT is the one you need to memorize for um exams. You don't need to know how it works. You just need to memorize that U P D equals DPT. So now it's going to antisocial personality disorder, which is another um mass media popular one. So basically, they are generally speaking, going to be mail because of epidemiology reasons and uh constantly fighting and argue with people and um contact disorder is the equivalent for under age 18. So for example, maybe you have a teenager who is constantly fighting uh not in school and also abusing animals. And basically, it's a psychopath. Again, you can't officially diagnose them as antisocial past disorder because their personality is said to be unformed until age 18. Before age 18. They have just connect disorder as soon as they hit age 18. And presumably they've gone from abusing animals to abusing people, then they get antisocial percentage order. And psychopathy is essentially on the severe end of the spectrum of anti social behaviors from presided Soldier all the way to look up being very psychopathic, right? Anxious and avoidant prostate disorders. So this is the one in the question. Um like we've discussed fears, rejection, avoid social contact and as an inferiority complex. Um dependent precise disorder. Um basically really needs help from their close ones because they are very helpless when alone and because they help us alone, they fear being abandoned. Um The differential includes anxiety disorder and reliant on others for competitive impairments. But of course, because percent disorders start in adolescence, um they're less likely unless they have a learning disability, they're like relax, likely to get a situation. We're trying to decide between cognitive impairment related dependence and actual dependent personality disorder. Uh Right. So that's a percent disorder questions done. Um Any questions while we are answering this question were on the medication section of the presentation now. Okay. So I would say the medication questions are high yield because it's very easy to write exam questions like this one. This is a very good exam question. Uh because if you have a member, it's a side effect of these medication classes, you're going to put the wrong answer. Um As I'm sure you know, the uh nice, nice guidelines technically say you can choose any of B C D for first line um first line treatment of depression. So if you picked be just because you thought it was first line, that's actually not an adequate rationale. Okay. Um Interesting. Some of the picked c drugs. Uh Do you actually know what c drugs are? Um the patient has depression uh which not be treated with um sleep drugs, they should be treated with antidepressants. So the answer is b it's SSRI. So the reason that the key key to this question is they wanted people to pick tricyclic because the patient is slightly elderly and tcs are more efficacious and elderly patient's. Um but um TCS cause urinary tension because of the anticholinergic effects. So SSR is more suitable uh here. So here's basically one, I couldn't find a branded logo for a tricyclic antidepressant, but here is just some typical, very popular, um branded uh drugs in each class. So we've got Valium uh Benzo class, we've got PROzac for the SSRI class and we've got effects er for the SNRI class manufacturing. We've got um Ambien which is salted um from the Z drug class, of course, in the UK. Uh we use topical more commonly than I'm an Ambien because Ambien is a very high abuse potential and also the black box warning for fatal sleepwalking. So there have been numerous cases of people sleepwalking off the balcony, sleepwalking the traffic, sleepwalking while driving, etcetera and dying because um they are in a pseudo sleep state induced by Ambien. Okay. So here's, this is by no means an official guideline, but this is just something that my psychiatry reds taught me and also common practice. So most cations should probably start with the SSRI because they are the most well studied drug class in depression. Um and they have probably the least um directly relevant um side effects that will make the patient stop the drug. So the classic side effects for SSRI uh sexual dysfunction, especially erectile dysfunction. Uh This is, this is the one they will ask most, uh most often for exams. Also acceptable. First line is the serotonin uh reuptake inhibitors classically venlafaxine. Um in the and they can cause nausea, business and sweating. Although the UK, they're more commonly used for anxiety disorders, um panic disorder and generalized anxiety disorder rather than um depression. Uh DULoxetine has a side indication for osteoarthritis pain. Then moving on, that doesn't work with called mirtazapine, which is a newer generation um antidepressant. Of course, it's newer generation because nobody knows how it works has a very dirty mechanism. It hits numerous different receptors. Um The classic side effects are weight gain and sedation. This is why it always does at night. It's very common in the elderly because it treats the produced appetite and weight loss. Also the sad indication for the population of breathlessness. So that's those those don't work. You're moving on to tricyclics as you know, tricyclic expressions are very dangerous overdose. Um They're treated with intravenous sodium bicarbonate. Very high risk of an overdose of cardiac arrhythmia, etcetera, and uh acidosis. Um very, very strongly cholinergic. Uh I use this specific Manami quiches. Can't see, can't P can't, can't say it on a presentation and can't spit. Um The reason is there's another um anomic which is uh was it as red as a beet matter as a hatter blind as a bat, um dry as a bone. Um that, and that one doesn't really cover the constipation, which I find to be a much more um common side effect of anticholinergics. And actually the flushing the medicine bit, you get that less. So I, I just think the other than the money is not very useful, um this economic is, is more useful. Um They also get postural hypertension, this is related to the colony ergic effects and they have a site indication for neuropathic uh allergies here. And then those doesn't work, you're going to the augmentation. Uh So in the UK, it's most commonly you're going to be adding to type in Orlando up in um uh lithium, very unpopular in the UK, even though it's probably very effective. Also lithium needs blood monitoring and has numerous um classic complications and side effects. And then also becoming increasingly popular. The UK borrow from the US is this combination called California Rocket Field, which is Venlafaxine plus Mirtazapine. And the idea is you get, you get a very, very, very strong uh re uptake inhibition and uh organism of the serotonin uh serotonin receptors. Um just seems to cause more side effects in my experience. And then lastly, if none of those work, then you're on the last line slash experimental therapies which are E C T ketamine. Um I have not seen TMS done in the tertiary centers in UK. So uh any questions for those antidepressants inside effects before we move on to the next section. And uh so Z drugs, by the way, these drugs, topical, these are sleep aids. They are meant to be there developed as a safer alternative to benzos, particularly overdose. Uh But they do the same thing which is that they induce a pharmacological sleep, which is unnatural and patient's build tolerance is um or slash dependence very quickly within about one or two weeks. Uh No questions. OK. Moving on. Um okay. Now we're onto the medication side effects part which again, these are high yield because uh they're very easy to write exam questions for. So 25 year old. Uh yes, what you call us and he has been given respiratory. Mm Interesting. So psychiatry is all about words. Um If you pick acathexia or even TDK, then uh I'm assuming you don't actually know what those are. So when the next few slides will be going into great detail, each of these. This is um yeah. So this is dystonia because yes, Torticollis got advanced mutation of his neck and the time frame fits as well. So uh Dystonia develops between with uh within hours a day of starting antipsychotic. So he's only been in psych for 24 hours. So he hasn't had risperiDONE for that long. That fits with Estonia as well. Acathexia is an inner sense of restlessness. This is not like aesthesia and target dyskinesia. Um You probably thought this kind easier. That's what this is. But this kind of easier. It does not mean dystonia, dystonia is a continuous contraction. This kind of easier is involuntary movements and also target itself as in retarded or retard. Uh It means slow onset because tardive dyskinesia usually uh it's quite late onset after months to years of being on anti psychotics. It's not tight. This kind easy. Either this is uh acute dystonia or acute dystonic reaction, um specifically uh torticollis secondary to risperiDONE, actually secondary to a dopaminergic drug. Sorry, I don't mean inhibitor respiratory. So, uh psych is very much just all about words and definitions, especially the drugs. Uh Let's go through all of these. So we're all on the same page. So first generation uh questions in the chat, by the way, um I am looking um first generation antipsychotics. These are the ones that are also called neuroleptics or major tranquilizers or typical. These all mean the same thing. First generation neuroleptic major tranquilizer, typical conventional. These are all five words for the same thing which is first generation antipsychotics, neuro Lepsis uh describes the slowing and the choir and the ramification essentially of the patient. You ever been to a high security site on patient's who are on triple, double or triple, even quadruple maximum B N F uh those uh first juries antipsychotics, um You will see basically they are almost zombified. Um That is what neuroleptic this means and what neuroleptics are meant to do. And there's three major classes that are most commonly still in use uh in the U K, although um some of them as common orders. So we've got the future pharaohs which are haloperidol uh routinely used for rapid tranquil ization because it is a major tranquilizer. Uh the thioxanthene class which are free Pantic so and psychopathic so very calm many years in the UK because they come in depots. Um hello parallel, also come to depo and specifically for acute phase, which is psychopathic sal. Um That one has a depo formulation which is also rapid onset. So it's excellent in mania and very like violent and behavioural schizophrenia where you want to sedate the patient and also hit them an antipsychotic at the same time. And lastly with a phenotype izing class, there are very few patient's left on Thorazine in the UK. It's a proper old school grandfather antipsychotic. However, phenotyping survive as uh anti emetics. A liver proposing is excellent broad spectrum antibiotic antiemetics still used uh in palliative care. So second generation is everything including an after cloZAPine because cloZAPine is the first atypical antipsychotic. So atypical means second generation means cloZAPine and everything else because cloZAPine is the first atypical antipsychotic. CloZAPine was atypical because it has at the time, a very weird mechanism relative to all the previous drugs. Um So Cosby and the new ones, they have much more a bit more loose abiding on dopamine receptors and a bit more off target uh serotonin cetera. Uh whereas the um uh more, more, more narrow spectrum effect, whereas the old drugs are very much, very dirty, very strong dopamine, uh dopamine blocking effect and also hear all kinds of other random receptors, which is also why um they can be very effective. Uh then the two major classes in the UK are um cloZAPine, which I should put in a separate category really from OLANZapine typing, although they're all similar structure and then the parents try Lurasidone, risperiDONE and paliperidone. So of course, risperiDONE, paliperidone come in depo form. Whereas the OLANZapine, QUEtiapine and causes being these are all um oral medications. OLANZapine also comes in I AM and has an off label indication of rapid tranquil ization as well. And the only third generation, the like the two of them for the uh I think the other ones practice pixel but basically the only quote unquote third generation antipsychotic is ARIPiprazole because it has a very weird partial dopamine agonist effect, which is supposed to cause less of these extra private side effects. So, extrapyramidal side effects, they are essentially drug induced parkinsonism movement disorders because of the dopamine blocking effect of the all of these anti psychotics. And they big for our drug news. Pakistan is um a kit dystonia, China dyskinesia and anesthesia. And then lastly, we will briefly cover neuroleptic malignant syndrome, which is the most feared complication of antipsychotic use. Uh It has a major differences between atypical and uh typical antipsychotics. So, atypicals are claimed to have less extra medical side effects because they have a bit more balanced um spectrum effects, bit more serotonin and the dopamine binding is a bit looser but they have way more metabolic syndrome. Uh almost every single patient on atypical antipsychotics at the antipsychotic dose. So no typing has 50 makes above Milan's up in 10 makes and above. Um they will be innovatively, there will be overweight and have drug induced diabetes and high cholesterol. Um That's just how the drugs work. It's probably serotonin related, they increase appetite as well. Um They also cause QVC prolongation. So some people say it's slightly less QVC prolongation than for example, haloperidol. But they're also way more atypical antipsychotics as a class. So that probably balances out and then they have a bit more of a narrower um receptor targets. So they have less of the antihistamine effects. Uh So many of the first generation antipsychotics are also anti histamines, for example, promethazine, which you commonly see as another upper tract drug in psychiatry. Um is both, is a retired antipsychotic. Now, it's mostly used for it's um sedation and antihistamine effects. Uh then close up in one to memorize cloZAPine called Reglan oxytosis, which is neutropenia. Uh And the classic question will be patient on cloZAPine has fever, mouth, ulcers and a sore throat and the neutrophil count is less than one. What will you do? Urgent FBC at middle hospital stopped cloZAPine blah, blah blah. Um Yeah, that's a closed up in specific effect. The other, other um OLANZapine QUEtiapine don't do that. This is specific to close up in and this is why cloZAPine was banned for 30 years before being unbanned before they realized because they realize that nothing works as good as closed up in. Uh So the generally speaking, uh extrapyramidal side effects are managed with cholinergic, mild. Um So drug induced parkinsonism, you manage them with PROzac codeine. The starting dose is 2.5 mg, tds orally and you go up to 5 10 tds and then um acute extra panel side effects. So, dystonia, you need to treated with IV anti cholinergic. So in the U S, that's diphendydramine here, it'll be a PROzac codeine. Uh you can also give them benzos in the second line as well. So uh best way to learn these drug induce side effects romantically is to watch a video. So let's hit play. Hopefully, this works. So this lady here has the classic uh facial movements of tardive, dyskinesia, tardive dyskinesia. So she has mouth sucking, uh she has uh tongue movements and she has eyebrow and eye movements as well. So, very much China test Kinesia is classically mostly facial and that is why it's very distressing for the patient. These are involuntary. Uh So as a caveat anticholinergic actually make it worse. This is the one A P S C that you usually treat just by switching to a different drug or reducing the dose. And the problem is it can also be irreversible and it appears um quite late uh in these old pictures, as you can see, uh this lady here for 61 years old sentence for three years and this lady here spasm of jaw symptoms for four years. So unfortunately, it can be irreversible once it starts. Uh next one, uh Christian chat questions, chat, next one acute Estonia. So again, the classic, it's not like dyskinesia, which takes a long time to appear. Uh it's very much, it's hours a days, early, early hours of days, medication reaction. Um These are acute sustained muscle spasms, um classically the neck jaw um and um oculogyric crisis, which is eyes. So, um this lady here, she has medical, medical might being a double main drug has metacarpal might um induced acute dystonia. She has multiple manifestations. So she has jaw dystonia and she has neck hyperextension and she has left gays deviation as well. She's not doing any of these on her own. It's because the metoclopramide uh messed her up basically. Uh too much dopamine blocking and just just and they treat her, give her the IV and economy and she goes back to normal as you can see. And uh let's watch another one. That one uh hold on, go back, go back. Thanks. Uh huh. I'm just gonna switch the screen gets again and that one So, all right, early this morning. Uh, so when did, when did you start having trouble talking, uh, earlier this morning? Uh, and did you take any drugs, uh, other, other than your prescribed drugs? Uh, no, you don't do cocaine or anything like that. Uh, okay count. So that guy has drug needs to Sonya and then, uh, they fixed him. Okay. Give him that I'd be anticholinergic. You have your right guard over there and support not quite 100% but it does go back to mostly normal. All right. Uh Let's go back. Okay. All right back. Uh So next Agathe Zia. So this one is the hardest to explain because I hope none of you ever have to experience it. But this is why the video comes in. So acathexia is an inner sense of restlessness which is very, very unpleasant and annoying patient literally cannot sleep because they feel like they have to constantly move. Uh So let's watch the video what it looks like. So, so did you hear that? Um She said um it's just something that she feels like she has to do. So it's not involuntary movements like the other side effect, it's a voluntary movement but they have to do it because it feels very uncomfortable not to move. So here is a nice summary table which covers the major types of E P S C uh also from Psychiatry PRN. So, uh for example, so for a Cath Izzie. A classic exam question would be patient started on for type in or maybe uh clo pixel for two weeks and then they're constantly unable to sit still in their chair, constantly moving about in their chair. Uh diagnosis. It's like aesthesia. So, but the moment the movements are voluntary, that's the difference from Estonia. Uh Pakistan is um and T D K. So uh any questions about E P S S before we move on to covering your maximum chicken syndrome going once, going twice, no questions. Okay. So uh there wasn't actually any questions on your elected malignant syndrome in the MSC A papers. But I think it's just because they neglect psychiatry questions. Um I think it's quite likely to come up in exams. So classically, uh the onset is either when starting a new antipsychotic or recent rapid dose chains or when switching between anti their context, usually within about 1 to 2 weeks. And there's a classic tetrad which happens in that order. So a patient gets confusion first, usually agitation that can be catatonia as well and they get extreme that pad rigidity and this is why the creating kindness goes sky high. Then they get the hypothermia which is partly ready to the tremors and partly autonomic. And then they get the autonomic instability with the tachycardia label BP, um tech NIA and the profuse sweating patient's are extremely unwell. They require I T U usually because management is largely conservative you can't give them Dantrolene. Um for hypothermia, you can consider E C T. But basically, um it's uh patient's are very, very unwell. Um, a common exam question will be to differentiate between serotonin syndrome and your elected Miletic syndrome since they're both psych drugs. So, aside from the actual class of drug, given the physical exam, findings are slightly different as well. So in serotonin syndrome, you get Cronus and hyperreflexia, which you don't in your letter medical syndrome, uh neural examination for some reason, you get very, you've got high rigidity but you don't get clonus probably because uh it's more of a muscle tone problem than a true upper motor neuron problem. Whereas uh serotonin syndrome, it is like upper motor neuron related and uh serotonin syndrome classically is a much more rapid and onset over 1 24 hours. Whereas uh near lesson, lesson jump takes a little bit of time to appear after um those changes. Uh blank slide, that's the end. Uh Here's the X. This is the book. Uh this is the only text book I've ever read cover to cover. Uh It's very, very good to psychiatry. It's very, very short, only about 200 ish pages. You can read it cover to cover maybe like one day, but it covers every single psychiatry topic you need to know for medical school um in just enough detail for passing exams no more, no less. Uh And then these authors, there are several of them are quite legendary. So, Doctor Stringer is an excellent psychiatrist who has retired after spending some time, but it is now running a coffee shop and doctor lips said he is the royal psychiatrist for Princess Diana. So a very legendary psychiatrist there. Uh So all the content has been crosschecked by him. That was the ent any questions from the chat. I have the slides. Yes, I will just edit them everything in sight and to make sure everything is cited and uh put all the questions from the chat in there as well and then I will send it out or rather, I'll send it to SMS. Well, then send it out. Perfect. Thank you so much, Vincent. Yeah, we'll, we'll, we'll get the slides out. Thanks again for this organ. Other pretty good one. Uh Some really good questions in there as well. Um Thanks everyone for attending to our next session is to be confirmed. So keep an eye on our social, but it will go on trauma and orthopaedics uh potentially next week. So, um yeah, keep an eye on our Instagram. But until then, uh yeah, Raymond. So if you fill out the feedback form that will give you access to both the recording of the session and then we'll have your email so we can send you across the slides. Uh But thanks again, Vincent, that was really, really, really helpful. No, I I'm quickly copying those chat questions from uh had to open a little chat. But yeah, thanks for calling everybody. Thanks everyone.