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Good evening, everybody. Um Welcome to this middle primary care network event. It's great to see numbers steadily climbing once again, this really cold Wednesday evening where it is where I am anyway. Um We're absolutely over the moon to have two fantastic speakers with us this evening going to be mainly led by Rosin Buckland who um is a core trainee in psychiatry in the Central North West London Trust. Um Also as a background of a phd in medical humanity. So we are indebted to you being here. We're really looking forward to hearing from you tonight. Also in the background, we have Doctor Zoe Sciola who is going to be speaking with us in a couple of weeks time in, in the next in our series. Um But will also be on the stage with me as we always do. We will spend about 45 to 50 minutes um running through um our presentation this evening and we will have some time for Q and A at the end. So I'd really encourage you um in the chat pop in any questions. Um I know Rosalind has said that there's going to be a wee bit of interactivity. So I would encourage you to engage with that in the chat as well. Um What you should see on the screen now, if you haven't already is the QR codes for the Med All app. If you're not already joining from there, please consider doing that. Um, for the next event, you can also get your certificates and register for everything coming up there as well. Um We have our events running almost every week. It's getting close to Christmas. I know everyone gets busy with various different things around this time of the year. Um So please do get registered and get things in the diary over the next couple of weeks. Um I am not going to hold anything back any longer. I'm going to hand over to Rosalind to share her slides. Um And as I said, I'll be here in the background and I'll be keeping an eye on the chat. Please pop any questions in there. Hello, everyone. Welcome to this series on Managing Oh, well, the Psychiatry series and our first lecture on Managing Anxiety. Uh We're gonna begin with a case study today. This is a real case study obviously anonymized. Um But a patient that we've seen. Uh So this is a 35 year old Bulgarian woman comes, comes to you with a six month history um of an almost constant feeling of anxiety, irritability, low mood and restlessness. She experiences palpitations. But when you ask her, she denies any shortness of breath or chest pain, Rosalind. I'm just going to jump in. I'm going to get you just to pop the slides up. It was me whenever I was sharing my wee ones has put yours down again just for everyone. Um The wee middle one at the bottom and then entire screen should get us up again. All right, here we go. Perfect. There we are. Is that better? That is us night? Perfect. Perfect. Here we go. As I said, we're gonna begin with a case study. Um And then we'll move through the kind of clinical implications of that study. Uh So this is our woman, um 35 year old Bulgarian uh with a woman with a six month history, almost constant anxiety, irritability, low mood, restlessness. Um as I said, she's experienced palpitations. But when you ask her, she says she doesn't have any shortness of breath or chest pain. She is experiencing obtrusive thoughts that she has HIV, despite having tested negative for it and having no recent sexual partners. And that's some of the intrusive thoughts that are going through her head again and again, she has difficulty getting to sleep due to worrying and has been eating less. She's been unable to work for the last month as a result, make it nice and easy. She's not got a past medical history. Um and just looking at her, she appears very anxious and teary um and quite restless with fast speech because in these cases it's very important to look at risk when we're looking at mental health. Um, I've got a bit down there denies, uh, she's had some thoughts of, kind of ending her life now and then, but no active suicidal ideation and no other risk factors. So no self harm. She's got nice protective factors. Um, and no particular kind of current risks to or from others. Uh, so before I go on to this slide, um if you could pop in the chat, have a little look at this er history of this woman, obviously, you know, we spoiled it a bit and we know we're coming with anxiety, but it's very important to think about what differentials um could be going on here. So if you could pop in the chat for me, just the things you want to rule out in this case, I'll give you a couple of moments. So we've got OC D generalized Anxiety disorder. Those appear to be the main two differentials that I'm that I'm seeing. Yeah, let's start with those. Um So we've got O CD and actually that's a very good shout and particularly how I've described it with intrusive thoughts that are going through again and again, we've got panic disorder or general anxiety disorder. Um You would want for the A CD to go into more kind of direct history of that, you know, is it the thoughts themselves? Is it, are they related to certain things, there are certain areas and that's when you'd be particularly careful. But we do also want to look at some other things. So we want to think about physical causes. So she's describing she has these worries, but she's describing some kind of tachycardia, some palpitations and obviously there are physical causes that can cause those two that might tie into mental health. Yeah, we and we've got some people saying check the thyroid, exactly, particularly in GP we wanna screen for them. So you're screened for your hyperthyroid. You're screened for your cardiac disease and uh pheo uh chrom cytoma as well. Just all things to bear in mind is potential differential. So you do your bloods, you do your eg um and you'll check your things like your hypertension and your, your red flags as well. So your headaches, your goiter, um things like that. We do wanna check if she's on substances unless is something we do for every um for, for a lot of mental health presentations, you wanna check. There's nothing tying into that. And this lady denied any drug or alcohol use along with O CD. One of the things we could think about is a somatoform disorder. So, are there kind of, um is this a kind of uh physicalized kind of worry? Is there, is it particularly about the body? And actually what we can see here is the physical symptoms are more consistent with panic attacks or anxiety. And actually, while there is a concern about HIV, it's only one of several areas which again is one of the important things to differentiate. Um and that it's not related to the actual physical symptoms she describes when we think about anxiety. Um obviously, one of the things that, that can kind of sometimes present quite similarly can be depression, which sounds a bit odd and they can be very clear sometimes. And the way it's presented here can be quite clear, but things like agitated depression, actually, you can have quite a lot of kind of restlessness as well. Um So you wanna check really for low mood, which in this case is present but not the predominant sy symptom. Um And again, with that HIV concern and its lack of kind of grounding in, in reality really, we wanna check that there isn't a psychotic depression element to this lady as well. And the last we think about is personality disorder. But again, that's from my other kind of diagnosis of exclusion. So let's have a little thing. We've narrowed it down maybe to panic disorder and generalized anxiety disorder and, and which is going on here and not on this page. I've just got the kind of um the Maudsley er, the ICD kind of description of them. So we know exactly what we're working with. Obviously, they're both presentations that most of us and particularly you working in general practice will be very used to, but it's important knowing exactly what our criteria are. So, panic disorder, um, recurrent panic attacks that are not consistently associated with a specific situation or object and that are unpredictable. Er, so that's important, it's not something that kind of occurs in a social situation, for example, which might make you lead towards er, social anxiety. So they're not consistently associated with a specific situation or object, they aren't associated with marked exertion which might explain it otherwise or with a specific exposure to actual dangerous situations. When we look at the actual kind of characteristics of them, it's very important that they'll be discrete. Um So they're separate events that they start abruptly. So they come on quite suddenly and that they reach a maximum within a few minutes and then they last at least some minutes more. Um So actually they come on very fast and sometimes you just, you hear people describing as in this case, almost constant uh anxiety or almost constant, they can use words, they can say I have almost constant panic attacks. And at that point, it's very important to kind of differentiate. Well, what do you mean by panic attacks? And are these things that are happening and then stopping or is it that you just continually feel pretty terrible, um which might lean you towards more of a, a generalized anxiety picture in terms of kind of our technical uh criteria for them, obviously, in practice clinically, um you know, we go by distress and we go by symptoms, but again, it's worth thinking about what is described as moderate and severe. Um, so to kind of get an idea of what is, uh, what those levels are kind of expected to be so moderate would be described as over four panic attacks, uh in a four week period within a month. So that would be, you know, without being particular times, it would be at least one a week and uh severe, you'd have at least four panic attacks per week, uh, in a month, generalized anxiety disorder, um, you'll, you know, you'll all know uh its presentation, you get prominent tension, worry, feelings of apprehension, and it's about everyday events and problems. So it's, it's happening all the time and it's important that this er, occurs in theory at least, er, for at least six months. Um, again, this is um, a slide that has quite a lot of detail. Um, it's from our kind of ICD diagnoses but, and it's not something you need to know specifically, but I think what's very important about it. Um, and I want to have a little think about is we can see you here that generalized anxiety disorder is actually um, well, panic disorder is a subset of generalized anxiety disorder. Um So there is a overlap between the two and it's important to notice as well that when we, when they say we need four symptoms, one of them should be autonomic. So in both of these kind of disorders, we would be expecting some kind of physical impact of them. So those physical impacts could be palpitations as in this case, uh you could have sweating, trembling or dry mouth. Um OK. So in terms of how one would begin to assess generalized anxiety disorder, um once we've kind of noticed that this is probably what's going on for this lady, we'd use our G A seven and that's what I think a lot of you will be using in, in general practice. It's a very short, um by definition list of seven questions just to kind of assess what is going on for, for these uh patients. So you ask them whether they're feeling nervous, anxious on edge, whether they uh are not, you're not able to control or stop the worrying, whether they're worrying too much about different things, whether there's trouble relaxing, um whether they're so restless that it's hard to sit still and that's quite an important one to have a little think about as well. Cos again, it ties in a little bit to that more physical impact that we can have and whether they're easily annoyed or irritable or whether they feel afraid as if something awful might happen. And you ask your patients to say how often each one of those things are happening for them. You know, whether it's not at all, whether it's several days, more than half the days or nearly every day and we assessed that over the last two weeks. Um So the idea is we get a picture of time that's long enough, um that we get a, you know, a AAA passable sample size. It's not, not just a one off day, but at the same time, it's, it's recent, it's memorable um for the patient, if we're looking at, if we get a score of five, that would be mild. If it's 10, that would be moderate and if it's 15, uh that would be severe. Ok. So having a little think about management, once we've, now we've worked through diagnosis um as you know, nice loves its step uh patterns. So we, we've gone for that here. So our step one management is just kind of assessment, education, active monitoring. But once we've kind of made that diagnosis and the patient's not improving or we're concerned, we can think about low intensity uh psychological interventions. So that would be things like individual self help um that could be facilitated or not facilitated. Um Or it could be psychoeducational groups. It'll depend on what's kind of available in your area. If the patient doesn't improve at that level or if there's marked functional impairment to start with, you don't have to, to kind of go through these other stages if you are concerned about the patient, um we move on to high intensity uh psychological inventions, interventions and that would be CBT or applied relaxation. Um, or, and we can also use medication. Um, and again, it doesn't have to be either or, um, step four if they're treatment resistant or there's very marked functional impairment. So, if you're concerned particularly about self neglect or self harm, uh, we can refer for specialist treatment. Uh, in our next slide, we're gonna think a little bit about exactly um, what those interventions might mean. So, again, this is a very busy slide. This is from our Maudsley, our Psychiatry guidelines, er which is why it's so busy and, and again, it's probably a bit more than you guys will know. It does a lot of the second line treatments, but I'd put it on there because out of interest really for you to have a little look at and I'll keep this slide up just for a moment. Um So you can also have a look at it yourselves. Um The key things uh to note about it. Um are that, um, it, it's all kind of, and we'll go through this again is our first line dog treatment that you can see just under crisis management. Um And we'll go through this on the next slide again because this is what really you guys will be expected to work through. Um So we'll start with SSRI S. Um And it's worth noting that those may initially make symptoms slightly worse. Um So we start with a lower starting dose. Um and we prefer FLUoxetine or sertraline. Sertraline in particular is, is cheaper. We'll go through, we'll go through that on the next slide. So you may have used that more. Um, SNRI S, um, would be the next line. Um, and then possibly pregabalin, er, is the, is the, er, nice recommended, um, uh, drug after that? Um, it's important. One of the things that might, may surprise you is if you can see that beta blockers here are actually our second line drug treatment. Um And that's interesting because II know they are used a lot in GP and I'm not saying, you know, not to use them a as such. Um because if they work for a patient or if a patient has particular somatic symptoms that you think they're really, you know, helpful, that's, you know, a perfectly legitimate thing to do. You know, if there are particular events that trigger the anxiety, you know, they're obviously shorter lasting, don't need such a long kind of duration of treatment. But it is worth noting that at least from a kind of psychiatry perspective and from a nice perspective, they are 2nd 2nd line because there's less good evidence for them and we've got some of our other drugs here. It's really important um that some of them you would not offer in, in primary care. So, er, things like QUEtiapine, you know, antipsychotics, obviously you're referred to us in psychiatry to start, er, if, if other treatments haven't worked. Um, and things like benzos, I would really uh probably try not to use if possible in primary care. We do use them for anxiety but only for short term use, maximum kind of 2 to 4 weeks. Really. Um I think it's also uh the reason, another reason I wanted to put this slide on is that I think it's quite good for having a little think about experimental er, medication. And that's because for some patients who may be more resistant to the idea of kind of traditional medication, it's something that either you could try with them or that they might want to try themselves and might bring to you um to tell you that they are trying. Um, so that's things like chamomile, it's things like er, ginkgo biloba, er, lavender oil and er, riluzole. Um But noticeably with that one, you'd need liver function. So you really wouldn't want your patients to be coming with that. The others, we do see quite a lot patients self um self treating with. Um, and it can, yeah, just, just kind of really worth knowing about um non drug treatments as you've seen first line here as on the previous slide, CBT, applied relaxation and as for everything uh or we can always recommend some exercise. Um So I know that's a busy slide. So I've just summarized the nice guidelines on our next page. Um So for nice, the thing that we'd start with would be sertraline and the reason is that, is that it's cost effective. Um, it's that SSR that we start with, but it's really worth noting that it's not licensed for, it's not actually licensed for generalized anxiety disorder in the UK. Um, so it's always worth noting when prescribing, but it is first line according to nice, if that's ineffective, you offer an alternative SSRI or SNRI. Um, and there are a couple of things that you want to take into account. Um, the first being, er, potential er, of withdrawal syndrome, er syndrome and that's particularly bad for paroxetine and venlafaxine. Er, there's a risk of suicide and toxicity in overdose, especially venlafaxine. So maybe Venlafaxine is one you want to potentially not, not, you know, put towards the kind of latter er, choices really. Um And you'll want to ask about things like risk. You want to make sure there's not a stockpiling of medication or a past history. We think about side effects profiles as with anything and obviously patient preference if those SSRI S or SNRI S are not tolerated, um, the guidelines are to consider pregabalin. I think that's something we're very reluctant to do often in primary care and that's understandable. Um It is a controlled substance. Um So you'd want to evaluate for potential abuse or the potential of dependence. And again, it, while those are the nice guidelines, if you're not comfortable with that. Um And if you've tried a couple of other medications for this patient. You know, I think very much a referral to secondary care would be, would be kind of appropriate. The nice guidelines again, are that if the drug is effective, we'd advise the person, er, to continue taking it for at least a year because there's quite a high likelihood of relapse. Obviously, that depends on the person. It depends on the severity of the presentation, but it's worth worth letting patients know that they may be taking these medications for, for some time in this case. Um You know, II know that we, we safety netted, there was some suicidal ideation happening for this patient. So it's worth thinking about what we do for high risk anxiety is one of those things that, you know, actually, we, we don't think of high risk. I think a lot of the time in the way we do things like depression or psychosis. But actually, uh I, you know, I recently worked in the crisis team and we, we actually did see a fair amount of it. Um and it, it is completely appropriate to refer to secondary um mental health teams for anxiety if it's unmanaged or if it's particularly severe um options from that point in the UK at least would be kind of um safe spaces or crisis houses, safe spaces in particular can be very useful for anxiety. So if you have patients who they, they're basically um can be things like drop in cafes run by charities or run by secondary care teams where patients can drop in if they are finding things particularly difficult at a particular time. So they can be very helpful in anxiety. In particular, if you have patients who, you know, need some help, calming down, need some help. Kind of just having that bit of reassurance. It's one of the things that, that you might well have in your local area, um, would be a kind of safe space or a kind of crisis cafe that you can recommend they go to, er, if they need kind of more kind of time specific reassurance. Obviously, if patients are very unwell, there's always the, er, option for inpatient admission or home visits from crisis teams. Um, and you can safety net, these patients with those crisis team numbers and of course, with A&E attendance. Um, do you think we should do questions now or should we continue on to the next part? We have a couple there, Rosin, if you want to just address a couple of those, if you're happy to, um, I can pop them up on to the top of the screen here, they should pop up. So, um sh she has asked, can Busprione be used alongside SSRI S and SNRI S or would it be sort of contraindicated to give together? Do we know I can't actually tell you off that because I've not, I've not used it myself. We tend not to Yeah, I was gonna say working in the crisis team, we also tend to stay away from that. I was actually looking online at the kind of interactions between, between the two and there's no significant interactions on the BNF. I think theoretically it would increase your risk of serotonin syndrome as, as with any of these drugs prescribed together. I think, what more is that? I was, I was, it was quite an interesting question. So I was looking and I couldn't see much data on whether there was an efficacy to it. And I think actually, yeah, it's just not a drug commonly used that I've seen either um for, for anxiety. So I I'm not sure I would do it, but I'm not sure there's any severe safety things as per the BNF um other than the theoretical kind of serotonin syndrome concern. Sure, sure thing. And again, similar um very, very rarely um come across, come across boum. Um Anthony has asked um with regards to nice guidelines. So sertraline being a first line recommended um has said, but it is the most effective or is it just the recommendation from the nice clinical knowledge summaries based on cost? Do we know mainly mainly cost is the specific justification for it? Yeah. Yeah, it's mainly cost effectiveness. It's one of those sort of bigger when you zoom out and look at the bigger picture issues. It's cost effectiveness. I had popped in a little bit just about the pregabalin being a first line recommendation. I'm in AE D job at the minute. And I just was wondering on your own thoughts on the risk of addiction. Yeah. So, so to be clear, it, when I say first line, it's not f it's, it's within our set of first line drugs. So it's, it's the third of the first of the first line categories of drugs. So you'd always go for your SSRI s first, then you'd do your SNRI. Then the nice guidelines are pregabalin. I, while that is the nice guideline, again, we're actually in secondary care, too, very cautious about prescribing it for anxiety, um, particularly because there's a lot of patients for whom anxiety over their medications may tie into their presentation and for whom in practice pregabalin may do more harm than good. We find, um, the argument is that, that argument that, that our kind of focus, that there is an argument that's going on about our focus on addiction being a bit kind of over emphasized compared to the benefits of it, which is, I think what ties into that nice guideline. But still in practice, we do, er, tend to even in secondary care, um, in practice, steer away from it as much as we can. So, II do feel that might be a point at which you might want secondary care um, advice. No, absolutely. Thank you so much. I was just being, being nosey as well. Um, I'll give one more and then I've seen a couple more have come through, but in the interest of time I'll let, let us move on. Um, so one last little one on the first half of tonight's presentation, the experimental drugs that had been mentioned to you, Ros and have any thoughts on Gander and Valerian root. Can they be combined safely with prescribed medications? Thought on that. So, uh, valerian root, um, in the interest of time, interestingly I II removed from this presentation because, um, you know, it's a bit of a niche drug and I didn't feel like we needed to go into it too much. But, er, actually in, in this patient's case, for example, er, she was taking Valerian root and we did describe, we did decide to ask her to stop that while we did the other medication. And that's particularly because there is a theoretical risk of it interacting with the other medications in ways that haven't been been well enough evidenced. Um, so in, in, in practice ones like that, yes, I would be cautious, um, about patients taking, it's also very important that a lot of patients don't actually know the doses for those more experimental and herbal drugs. So, if you do have a patient who is taking them, er, very a a and I, again, I'm thinking of this case, um, they often don't realize that they also have, um, maximum doses and this lady was, I think taking about 10 valerian root pills a day. Um So yeah. E exactly. II would probably, um there's very little evidence I might well ask patients to try and wean off them unless there is something that very much works for them. And it's clear that there aren't contraindications. Perfect. Rosalind. That's really useful. Um Thank you everyone for your questions. I see more common in the chat. We'll try to get it to a few more of them at the end. Perfect. So this is the first part of what's gone. What's happened with this lady? We've diagnosed her. We've started her on treatment. Unfortunately, as in many of these cases, uh she's come back for a review in four weeks and she's not feeling much better. So she's been started on sertraline by you. A nice first line drug. Herba remains very anxious and she's asked again to change her medication. So you review her in clinic. She describes herself now as not good and is concerned that she has serotonin syndrome. When asked to elaborate by you, she complains of low mood stating that I want to die because my brain is not working properly. Over the last month, she's started experiencing discreet episodes of anxiety associated with shortness of breath, palpitations and sweating. Um You know, kind of guesses considering what our presentations been, what that may be at these times. She feels like she may be dying, they start suddenly and reach a maximum point of distress quickly before self resolving. Then not associate with confusion. She's been taking her sertraline at half doses 25 mg due to concerns over possible side effects. Uh You do an examination and you find that her pupils are equal and reactive G CS 15, no tremor, sweating, flushing, no hyperreflexia, rigidity, myoclonus and her new score is zero. It might in practice be a little bit high if she's anxious and tachycardic, but it shouldn't be too high. Um So having a little think uh about Serotonin syndrome, what to if you could put in the chat, what the symptoms of that are that you might be looking out for. I've given you a couple of clues in the examination, I'm afraid. So, yeah, I'm not see, I'm not seeing anything, anything yet, but I mean, maybe we can pick out stuff for, oh, oh, hyperflex increased anxiety, sweating. Yes. And they are the key ones that you're often looking for because it elated people. Exactly perfect. Um So that kind of sense of sweating is one that really stands out with it, um that you can have a high temperature. Um And the reason hyperreflexia is really important is firstly, um that it, you know, is a clinical sign that you can look for, but also it's a way of distinguishing it from things like neuroleptic malignancy. But let's go through some of the symptoms here that we're looking for. So Serotonin Syndrome, um it's potentially life threatening drug induced condition caused by too much serotonin in the brain synapses. And that often and, and, and the risk of it is that it can come from quite a lot of our, er, psychiatric drugs as we will go through later. And as people have noticed in the chart, it can come through, um, it kind of interactions with other medication as well if you, if a patient does present with it, um it would be uh there are different levels of severity which would have different symptoms. Um So if it's mild, um they might describe anxiety, they might have nausea, diarrhea. Um and when and some insomnia, when you kind of do an examination, you might see some hypertension, tachycardia and that really key sign that someone put in the chat of hyperreflexia. Now, what's interesting about it when it's mild and, and difficult about it when it's mild, is that a lot of those obviously symptoms really just cross over with anxiety. I mean, the, the clue is almost actually in the name there. Um And you might well have nausea and diarrhea as well from anxiety as well as insomnia. So that's when those kind of physical signs become more important to rule out if it's something you or the patient is considering when it's moderate. Um you start getting agitation. Um So kind of step up from anxiety, really get myoclonus tremor, um mydriasis, flushing, um diaphoresis and a low uh potentially a low fever as well when it's severe. Um, it can be life threatening. So, really severe hyperthermia, you get confusion rigidity and it can lead to kind of respiratory failure and death. Um, so if you do suspect it, um, it would be a kind of medical emergency, you'd want to stop the medication, your, you know, you'd want to stop the medication yourself and you'd want to get them to A&E on the right of this chart. This isn't something you necessarily need to know. But I think it is important to think through what would be done for that patient. Once they'd gone through A&E, if it was mild, we'd start treating them with some benzos once it starts getting moderate and severe, um, they're doing things like cooling, they're doing things like fluids, they're doing things like, um, Cipro Heptadine, we're doing the cardiac monitoring, um, and kind of so on and up until kind of patients need kind of sedation and, and quite serious interventions. So, a little thing about drugs causing Serotonin syndrome. Um, and as you can see, a lot of our, er, a, a big kind of um, uh contributing factor can be our antidepressants and our anti anxiety medication and that's particularly important because obviously such a large portion of the population are now on those medications. Um, so that would be SSRI S, SNRI S TCA S Maoris and, er, lithium Can as well. Herbal medication, Saint John's Wort, um, as it often comes on, it feels like it causes everything, but this is one of the things that can also really um interact with. So, in terms of herbal medication, that's one to particularly, er, look out for analgesics are the other er, really big um factor that we can see, you know, a lot of patients with anxiety with depression, you know, it may be related to physical causes, it may be related to pain. Um and things like traMADol, fentaNYL and pethidine will all kind of er worsen, er, contribute to that kind of serotonergic burge burden. We've got some of our antiemetics there that you can see. Um and it's also very important to, to think that again, um that some of our recreational drugs can contribute to. And again, that's another reason why that drug screen um is particularly important to do before starting patients on kind of psychiatric medication. Um, so cocaine, for example, MDMA, uh amphetamines and LSD can all also increase your serotonergic burden. So, having a little think about this patient now, er, we've had a think about what, what serotonin syndrome is, but why isn't this Serotonin syndrome? And this isn't a call that I would necessarily expect you to make if you're worried again, like I said, just sending the patient to A&E it can be life threatening, better to be safe than sorry. But I think it's quite interesting and less commonly spoken about is, is why it might not be. Um And, and just thinking about it here first broken it down into a couple of things. Firstly, character. So her symptoms aren't really in keeping when you clarify her understanding of it, they actually don't meet the criteria. So she says, I feel like I'm dying because of low mood. And those symptoms are more in keeping with panic attacks than the ones we've listed the timing. So the episodes self resolve within minutes, which you wouldn't expect from serotonin syndrome dosage was a big one here. So really small doses of SSRI s involved. Um Most severe cases you'd expect kind of interactions, maybe an SSRI in a Maori um or something like that. We've got a reassuring examination um and observations as well and it's also very worth bearing in mind that there are alternative differentials. So this lady has a history of health concerns. Um So she's got that disproven H HIV and they feed into her anxiety. So it was really important in this case to strike a balance between recognizing her concerns and the potential to develop side effects while not over investigating. So, you know, ii wasn't gonna go through the whole differential again because we've made it quite clear that this is, this is panic attacks, this is what's probably happening for this lady. Um And as I said, there's an overlap between the two. so one can become the other or stop or, or kind of contribute are nice guidelines for management of panic panic attacks. Quite similar at the beginning. So, start with that education, start with the low intervention, uh, psychological interventions or step three if it's mild to moderate, um, it's, it's individual self help again, but if it's moderate to severe, we go for CBT or an antidepressant and that's slightly different in its wording from, er, er, generalized anxiety disorder. Um, because we tend to the, the technical advice is that the antidepressant you'd go for if it was long standing or the psychological intervention was ineffective or inappropriate. Now, in practice, obviously, um if a patient's life is really kind of impacted, we'd probably go for both and depending on how your waiting lists are. Um But just to know technically medication here, um there is evidence for SSRI S, SNRI S and TCA S. Um so tricyclic antidepressants, but with tricyclic antidepressants, we always advise caution due to the overdose risk. Um So they wouldn't be probably the kind of ones that we would recommend starting a pa a patient on. Um, and there's a lot of monitoring and more complicated things with them, the licensed medications um that we do have and in this case, sertraline is, is licensed. Um There's also citalopram, paroxetine, venlafaxine, and escitalopram. Uh Again, in this case, we would not try not to prescribe benzos. Um And that's because it might be tempting to, you know, there's this very obvious kind of distressed patient and Benzos might calm them down. You know, you can see the logical thinking within that but actually the evidence shows that there's a long term, uh, worse outcome in that case. Um, we also wouldn't prescribe sedating antihistamines, um, or antipsychotics, er, again for quite similar reasons. Um, so what, what, what kind of did work for this patient? Well, she remained a high intensity patient and, er, she was escalated to secondary care services, um, because we've tried a few things they haven't worked. It's completely appropriate. Um, the sertraline was changed to a escitalopram for her, but on the condition that her previous antidepressants be removed from her house first due to overdose risk and we did psychological input as well. Um, so CBT for this lady and I think that's the end of my slides. Yes. Fantastic. Rosin. Thank you so much. Um If it, if it's ok with you for um, a couple of minutes, I'll go through a few more of the questions that had came in if that's alright. Um, so I'll, I'll jump to the ones based on that second part of the um talk and then, um, we can go back to a few of the ones that were, were from the, from the first part as well. So, um, again, Shuba has asked about how soon would we expect Serotonin's symptom to happen? I think we touched a little bit on this, but obviously in general practice, particularly that patient coming in with temperature, a bit of nausea. A bit of diarrhea could very easily be diagnosed as a viral gastroenteritis. Um, that's concurrently been there. So how can we differentiate those things? Maybe just to briefly go over that again. So usually it would be, it would happen quite quickly after, um, you know, starting or changing a medication. Um, so taking the medication, so usually we'd expect within a day, um, we'd expect it to be within the kind of, er, probably expect it to be within the half life, um, of, of the medication, um, itself. So quite relatively, uh, relatively, um, rapidly within, yeah, the first few hours or within a day. And again, that's another way that we can differentiate from neuroleptic malignancy syndrome, which is something we get with, you know, antipsychotics and things because that's a bit more subacute. So that would be kind of days to weeks. So, yeah, quite a, quite a fast, um, onset expected from Serotonin Syndrome. But again, it's, it's Serotonin syndrome is interesting and II put it in the teaching because it's rare and we don't, you know, we don't see it a huge amount, you know, I, you know, psychiatrists can do their entire careers and see it, you know, a couple of times. Um, so it's one of those ones that it, it's just better to be safe than, than sorry on it most of the time it won't be. But, but we're always a bit careful with it. It's about having it in your, in your differential, I guess, which at that first point of contact, be it in general practice or emergency department being the two main ones having it just, they're in the back of your mind. Um, but usually the answer is we expect within 24 hours of taking the medication. That makes sense. Always do your drug history. Any new medications have they taken cocaine last night? Yeah, that is also true. That is also true. Um, I has asked about differentiating between malignant hyperthermia and serotonin syndrome. And again, I guess we kind of maybe have covered that a little bit there, but maybe just a little comment. Yeah. Yeah, I mean, sorry rosa, I would also say the context of it would be what would drive, how I would assess because they are quite similar in their presentations. Um, to be honest, I don't know that much about malignant hyperthermia apart from kind of, it can cause kind of severe reactions to, um, in kind of certain cases of anesthetic drugs and exercise and heat exposure. So I guess for me it's if there's a history of a medication change and then they're presenting and it's a serotonergic med medication, that's kind of what would, what the context of it would, would sway me. There are some, there are some, there are some particular things that one might, might look out for. So, I mean, the, the time, the time onset uh is, is a very key one. So, um, Serotonin syndrome being more acute within an hour, neuroleptic N MS being more gradual, days to weeks. Um, the drug, as you said, Zoe, it's the, the drugs themselves and the history of it. So, you know, you're looking at your kind of antidepressants and the ones we listed, er, for your, um, serotonin syndrome. Whereas N MS, you're looking for your antipsychotics really. Um or a kind of sudden cessation of dopaminergic syndrome, uh agents like levodopa in terms of the actual presentation itself, like you said though, they, they, they can be quite similar. So you've got that tachycardia in both, you've got that raised BP in both and you've got that hyperthermia in both, which is why they're very kind of easily um confused and, and, and rigidity in both so that they do present very, very superficially kind of uh not just superficially, they present very similarly. There are a couple of things that can um differentiate between them. It's a little bit more textbook than necessarily as helpful in practice, but, but probably worth knowing. Um with serotonin syndrome, you would expect hyperreflexia, whereas with N MS, you'd expect hyporeflexia. Um so in your serotonin syndrome, you hyperreflexia and you get clonus and tremor. Whereas in N MS, you're hyporeflexia and you get kind of what lead lead pipe rigidity. Um classically your pupils in Serotonin syndrome as well be dilated and normal, er, in N MS. That's not, they're the ones that we often, they're the two kind of physical signs that we look for as a difference. But again, if you're in, er, concerned about either of those things, um, I would, you know, both of them, both of them medical emergencies. So please send them across. Um, but that's, that's the technical. Yeah. II think the question was asking about malignant hyperthermia rather than N MS. But that, but I absolutely agree with everything you just said about N MS and I think it's really important to be very clear on the differences and exactly like you said in the reflexes and in the pupil dilations. And actually, I think when we go into psychosis and antipsychotics, I think we should cover it because I think it's absolutely key because often they're so um they can be very easily confused. I can't see the comments in the chat. Yeah. No, no, totally. Totally. My mind went straight to the usual confusion between, yeah. No, it was a very niche question. So I was uh Oh yeah, absolutely. Absolutely. Um Thank you folks. Thank you.