Psychiatry 1
Summary
This on-demand teaching session is designed to help medical professionals understand the basics of taking a psychiatric history, particularly when it comes to managing depression, mania, and anxiety. The session will cover the Mini Mental State Examination and review the distinct areas of appearance and behavior, speech, emotions and mood, thought, perception and cognition, insight and judgment, and risk assessment. Participants will have the opportunity to ask questions, discuss their own cases, and learn about medical investigations and biopsychosocial management of depression. Join now to gain a deeper understanding of psychiatric history taking and learn the tools you need to diagnose and treat depression.
Learning objectives
Learning Objectives:
- Identify and explain the criteria for a diagnosis of depression according to the ICD-10.
- Describe the differential diagnosis of depression and explain which aspects to consider when investigating a new psych patient.
- Explain the biochemical aspects of depression and list the most commonly prescribed antidepressant medications.
- Outline the biopsychosocial approach to depression management.
- Describe and demonstrate the application of the Mini Mental State Examination (MSC) to assess a patient's mental health.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Tree. Um Just the first few uh topics and at any point, I'm very happy to answer any questions. Um Please make as interactive as you guys want. Um, if you have any comments or anything throughout the time, either use the chat or feel free to speak out. I'm very happy to answer any throughout the, throughout the session. So, um I'm going to very briefly cover the MSC. So that's the mini mental state examination and then go into a bit more depth with, into depression mania and anxiety and we'll do a couple of questions throughout that as well. Um So to start off with taking a psychiatry history is like every other history. So you've always got the presenting complaint and the history of presenting complaint as well as the past medical drug history and social history. But where it's a bit more nuanced is getting that history of presenting complaint and knowing exactly kind of what to ask as well as getting the past psych history. So, have they had any previous admission's, um, have they been on any previous treatment? What other medications have they been on? Because this is all really important to build a kind of a long timeline of their mental health in general and the social history aspect is really important. So asking about drugs and alcohol especially are the most important ones as well as social circumstances and things like depression or even in old age patient's because this is really going to change the man, the management or kind of affect how we discharge them and where we discharge them too. Um The same with personal history just to get a bit more background of the patient and who than what they are, what they're like. Um So the MSC um surely you all have heard about this. Um And the way that I remember it and the way that it goes that the way that I write it down is a septic. So a for appearance and behavior s for speech, um IV for emotions or mood and affect um thought um perception, cognition, insight and judgment and then risk assessment. Now, can anyone tell me what goes in each aspect? Just a couple of um thoughts about, what would you write about in the appearance as an appearance? Bit of the MSC or your parents and behavior? Yeah. Clothing. That's right. Um So are they well dressed? Are they Kempt? Um Do they smell fine or do they smell like urine? Do they smell like they haven't bathed in a couple of days? Um Yep. So I contact and report. So report is really important. Are they trying to engage with you? Um And do they engage properly or are they kind of looking off to the side or are they just not making any eye contact look very down? Um So those are kind of the things you want to look for in appearance and behavior. What about in uh mood? An affect you can speak if it's easier rather than typing? I don't mind. Yep. So what's the difference between objective and subjective moods? What does it mean? Yeah. So uh Ludovica says, um subjective is what the patient says? And that's right. So, um and then objective is what you see as the, as the uh person doing the examination. Um So we did skip speech, sorry guys. So for speech, um we'll talk about that in a second but um for mood and affect. So um like you said, so subjective is what the patient says. So I feel low but if they're actually like having an appropriate um range of affect throughout the assessment, so, are they smiling? Are they um are they smiling at appropriate times? Are they crying at appropriate times? If not, then you can say that it's incongruent. Um So say they're talking about their dad dying and they're laughing um or if they have a label mood. So throughout the interview, in a very short space of time, they can go from hysterically crying to hysterically laughing with no, no, not no obvious input or cause for that. Now, coming back to speech. Um so you want to talk about the rate tone and volume. So the rate, how quickly are they speaking tone? Are they talking kind of in a normal tone? Um kind of goes up and down or are they talking in a very flat tone or a very elevated tone with mania, for example, and same with the volume. Are they shouting all the time? Are they talking really quietly? Are they mumbling? Um This is all really important depending on what presentation they have? Okay. Um So for perceptions or, well, let's go with thoughts first. Um What kind of things do we look for in thought? Yeah. So manage. Yeah. So form content and uh so possession. So um there's thought flow and then this thought content, so or form um so thought form or flow is basically how, what direction does the thought take and how do they talk to you? So in a normal conversation with you should usually kind of follow normal flow. So your thoughts should link up and it should make sense. Um Sometimes patient's can be tangential, which means that they go from talking about a topic and then suddenly deviate and then never come back to your question or answering the question. Um or they have uh circumstantial so they'll, they'll deviate but they'll come background. So that's why it's circumstantial. Um uh flight of ideas is very common in mania. So they'll go from one topic to another with no connections and your, it's very fast. Um Thought content is more about what is in the thought. So, do they have any delusions? Do they have, think that people are following them or people are trying to poison their food? Um Are they, do they have any suicidal thoughts in a depressed patient? Um And then thought possession is specific to schizophrenia usually where you ask them specifically, do you have, do you feel like someone is putting thoughts into your head, taking thoughts out of your head or that other people can read your thoughts? Okay. And uh the last few, our perception, um cognition, insight and judgment. So, uh perception. So are they talking about any hallucination? So, visual auditory or factory, um do they have any aspects of depersonalization or do realization um in the cognition aspect, especially for the elderly patient's and sometimes schizophrenia, patient's, you want to see if they're oriented to time place and person? Um do they have any insight into their condition? Things like OCD will have insight, patient's will have insight into their OCD but sometimes um in paranoia or mania, they won't necessarily have um insight into their condition. Um And then, so judgment or capacity, so do they have the capacity to make the decision to be admitted as an informal patient or continue care in the community? Or do you feel like their capacity is impaired based on their mental health presentation. And then always remember that in any MSE you want to risk assess. And this is a really important part. And this is basically the bread and butter of any psych placement. If you're the one choosing to admit or, or um continue work in the community because whether they're a risk to themselves, uh two others or, or they have a risk from others that can really change whether someone is admitted or it stays in the community. Okay. So the first question, um so have a read and write them down in your book and then we'll or in ipads or whatever it is that you use now um and put them and we'll talk about them at the end of this section. So here are the uh few questions. So if you want to have a read, I'll give you about uh a minute or two to have a think about this and then we'll um go onto the next section. Okay. Um So I'm going to move on is, does anyone want more time? Okay. So we're going to talk about depression. Um So depression in the I C D 10 is defined as any persistent low mood loss of interest and enjoyment as well as other uh symptoms. And so what, how you define it is you have to have these three core symptoms. So you have to have low mood, uh low energy. So energy er and anhedonia which is lack of pleasure of do in doing things. And these are the three core symptoms. Now to, to uh stratify depression, whether they have a mild, moderate or severe depression, depression, uh at the time, um you want to look at the other um extra symptoms that they can have, but they need to have at least two or three of the core symptoms. Now, if they have any features of psychosis at any point, then they're immediately classified as a severe depression, depressive episode. Um So the futures of psychosis include any hallucinations or any delusions. Um They can get nihilistic or persecutory delusions or um depersonalization as well. Um So, when looking specifically at uh depression, you always want to consider organic psych uh psych and then other conditions. So this is the differential diagnosis triangle. And you always, whenever you think that patient has depression, you want to rule out the organic causes first because you can treat those in different ways. And then we go into the psych conditions. So things that can cause depression in um terms of organic things can be hypothyroidism. It can be um dementia, it can be vitamin D and B 12 deficiency. And all of these are really important to think about because you can treat them rather than giving antidepressants. Now, the way depression works from a psychological perspective is that you have this specs triad of depression. So the person will feel will say that they are a bad person that things won't improve in the future and that their life is terrible, having those feelings of helplessness, worthlessness and hopelessness. And this is how we can treat um, depression from a psychological perspective. But before we do that, we want to talk about the different investigations. So whenever you have a new psych patient, always start with an M S C as well as a full history and the risk assessment, never forget the risk assessment, then you can get a collateral history, which is really important, especially in patient's that are comatose from their depression or they are to do to disengaged from your conversation to actually give you a good history. Um the physical examination in the routine bloods we've spoken about to rule out any organic causes and then you can do things like rating scales, um like the Becks depression inventory or the hard question. Er and if anyone is over the age of 50 and they're presenting as a first presentation of dementia of depression, you should always do a scan of the head, either CT or MRI. MRI is usually best because you can look for traces of dementia, which is a very common cause of depression in the elderly. Um And with any presentation of uh in psych, the management is always biopsychosocial and you've probably heard everyone talk about it millions of times. But from depression point of view, the biological aspect is antidepressants. So you can have different classes and they act on different receptors. I'm not covering this specific pharmacology in this talk because it's, it's not really necessary for pieces, but it will be necessary for your exams. So have a look at those. But the most common ones are SSRI s um things like citalopram, uh sertraline and FLUoxetine are the main ones that we use. Um But things like N S R I S and T C A s are, are used kind of second line. Um if they have moderate or severe depression, consideration of adding an antipsychotic is really useful and E C T can be used as well depending on whether they have um whether it's unipolar depression. So they just have depression or if they have bipolar disease. Um bipolar effective disorder and having an episode of depression from that. Then, uh psychologically, we've spoken about Becks triad so that helplessness, worthlessness, um hopelessness. Uh and that all can be targeted in CBT and um to look really cool in your paces. Um You should say if, if you get a patient, you can refer them to I act which is or they can self refer through their GP, it's basically um the psychological therapy service and you can um the triage you and they do on either online CBT, telephone CBT or face to face CBT as well as um kind of referring you to more, more uh 1 to 1 therapy if that's what they feel like you need. And it's a really good thing to show that you've been going to placements and that you understand the system. If you mentioned uh things like that, then social aspects. So this is why it's really important in your history to get a good social history because if they are depressed and they've come in post a suicide attempt, um then if they, if you just send them back home where nothing has changed, say they're, they're still alone. Um And the loneliness has caused their depression, they still don't have a job. This is all really important things to think about and how you can support them too, then uh improve in their depression and uh and then the mental health and improve and make sure that they don't relapse again, okay? Any questions about depression so far, okay? Um Just feel free to put any, as you get any questions as they come to your head's in the uh chat and I will stop and answer them okay. Um In terms of self harm. So this is a common paces station so the patient can come in with um a self harm attempt or a suicide attempt and you have to counsel them. Um in terms of any self harm attempt, always start with an A T E and make sure that you treat the organic cause or whatever the actual self harm was. First, then you can take a proper psych history and deal with the psychological aspect because that the actual attempt might well be what, what kills them first. So you want to see if they had, did they overdose? And if they did, you can look on talk space for how long you need to monitor or what the treatment might be or what the side effects might be. Um, do they have any lacerations or cuts? If they're superficial, then they're very easy to, um, to heal and look after you can just use steri strips or you can just clean them and leave them alone. Um, if they're deeper, then they may need plastic surgery or other interventions. Also ask what they, um, you want to know what they used to, um, to self harm because if they've used a rusty knife, then you may need to think about things like tetanus um, injections. But if they're using like a clean knife, then it's, um, then that should be fine. Um, and risk assessment is really important. Now, um, you want to know how they, how they did it when they did it and why they did it. And if, since that, since doing it, do they regret it, if they don't regret it or they had the intent to die? Um, then these are higher risk patient's because, um, they, if you let them go, they may try again, especially those that have planned carefully written a suicide note or, um, attempted to, um, that have found a time when there would be no one in the house or where no one would come back to, to look up to look for them. Um So, yes. So if they are high risk, then they'll need to be considered to be admitted onto a psychic psych ward. Um If not, then they can be, they can be managed at home depending on what support they have at home and whether um there's a, there's a crisis team available. Um and they should always have follow up afterwards, things to cope like strategies that you can advise them, especially for patient's uh more of the borderline personality disorder type where they use self harm as a way of coping, you can kind of redirect them to other um strategies such as um distraction techniques or using um bands, elastic bands or using a red marker. So it looks like they've, they've cut themselves rather than actually cut themselves and that can help, released the same amount of like dopamine um but not necessarily cause the damage that others that self harm would. Okay. So um now let's go back to our questions. Um So for the first one, um does anyone want to see what their diagnosis is? Yeah. Um And how severe would you say her diagnosis is? So, yeah, so she's depressed. Okay. Marder any anyone else want to suggest any others? Okay. Why are you saying moderate? Why are you saying severe Marina? Do you want to expand on why you think it's severe. Okay. Um, so she's got the main ones. Yeah. Uh, so she's got the, um, she's unable, she's lost interest. Um, she's got a low mood. Um, she's, yeah, she's lost weight. She's unable to sleep. Um, and she's got the energy as well. So I would say it's more moderate. Um, but, I mean, it's all moderate and severe, usually classed together in terms of risk unless they have psychosis as well. Um, what other investigations would you guys say to do? Yeah, TFTs. Yeah. So, in a young female, uh, thyroid function is, is good thing to think about, especially if she's losing weight, she might be hyperthyroid. Um, and all the other investigations that we talked about earlier to use the knees, um, just the usual bloods, maybe a physical exam, but nothing else, particularly apart from like TFTs, uh, anything extra that I would think about. And how would you manage this lady? Yes. So CBT would be really helpful for her. Um, but given that she's a moderate case of depression, moderate to severe, um, I would also start her on antidepressants, um, just to then make sure that because the CBT, unfortunately, the CBT waiting list is very long. So if you start her on the antidepressant and then by the time that she gets her appointment for CBT, it would, um, she would be in a better place to engage with CBT and then maybe we can, um, take her off the antidepressant. Yeah, metas a pine would be a good idea. Um especially yes, like you said. So, Mirtazapine is known for specifically weight gain and uh to help to improve sleep. So I think that would be a good one to start for with. We usually start them in our more elderly populations or um anorexia patient's. But I think in this case, it would be indicated as well. Um Obviously ruling out that she doesn't have any like thyroid problems. And then the last question that you should ask as always is make sure you ask the risk assessment questions. Um, has she had any suicidal ideation? Um, has anyone, has anyone, is she a risk? Is she at risk from others? Is anyone making her feel like this? Is she being don't know, bullied? Is she in a, um, is she in a abusive relationship? So these are all things to think about? Okay. Uh Any questions about depression so far? Mhm. Okay. Uh So this is our next one. Um I'll give you a minute. Okay. Uh Does anyone want any more time? Okay. So we're gonna talk about mania. Um, so mania is any episode of the symptoms we're going to talk about lasting for more than one week and affecting daily life. Now, there is a difference between hypomania and mania. So hypomania will have the same kind of symptoms, but it will be for a shorter amount of period and they'll still be able to um function normally. So achieve their ADLs normally and they'll just have these symptoms as well. Um But mania will actually affect their life um uh their daily life and it will last for longer than a week. So the symptoms to look for all of these, but the more serious ones that we want to focus in more are things like psychosis. Uh the grandiose delusions, um they can have other person persecutory delusions and um pressure of speech and flight of ideas is a really common one for mania, mania patient's um okay. So mania can present as an isolated incident. And again, when you have just mania, then you need to think about the different causes of it and will come to the differential diagnosis. But mania usually comes hand in hand with either bipolar effective disorder or schizoaffective disorder. I'm going to focus more on the bipolar disorder. Um So in bipolar, you will have an episode of mania and another effective episode. So that can be depression that can be hypomania or mania as well. So this is a cool graph from osmosis and they describe it very nicely. So you can see here that um the average person will have highs and lows in their life, but they won't reach the levels of hypomania mania or depression. If you have uni polar depression, um you will have a normal mood and then you have very low lows but not necessarily high highs, then if you have bipolar, ignore the one and two, that's, that's not a differentiation that we use here necessarily in the UK. Um So you'll have episodes of depression, you can have episodes of mania, you can have episodes of hyper mania, you can just have to manic episodes and that will class as bipolar, bipolar effective disorder. Um or you can have a depression depressive episode and a manic episode. So um differentials for mania, the most common one is drug induced. Um And we see that a lot and so they usually get admitted onto the ward for a couple of days. Once the drug is out of their system, they calm down and you trial them off the antipsychotics or the, the medications that we're going to give and then see how they do. Um And that, that's the most common one, especially in younger populations. Now, patient's that are already established, bipolar patient's will, will be on medications that uh will be like mood stabilizers or antipsychotics. And so we'll know that they are having a manic episode induced by the bipolar dis disorder, but they also can be on drugs. So that's always think about drugs in this case. Um but other organic causes, affecting the brain are always important like dementia, frontal lobe diseases and um steroids. Um So for this, uh collateral history is important. Um the MSC and risk assessment is really important and urine drugs, drug screen. So, um it tests for any, in every drug. And, um, you can, you can guess quite, you can see quite easily, um, what they've been taking. So the management of an acute episode of mania is different to the management of bipolar disorder. So, an acute episode of mania, you want to stop all the medications that they're taking. Sometimes patient's will present to the G P 23 years ago with an episode of depression, severe depression, they'll be started on antidepressants. Then a couple of months later, they'll present with an episode of mania. And that's usually um undiagnosed bipolar disease at the time. Um So starting bipolar patient's on auntie's antidepressants can tip them over into mania. So look for any of those medications, look for steroids, new, new, uh when you recently started patient's on steroids, they can either go into mania or psychosis. So that's also important to think about and then look at their mom, their food and fluid intake because when patient's are manic, they have reduced food and fluid, they don't eat, they don't sleep as much. Um And they, they engage in all sorts of um risky behaviors. So, if a patient has, is this is their first presentation and they've never had a treatment before. You usually start them on an antipsychotic. Um Now we use a lot of these new anti psychotics like QUEtiapine, OLANZapine on the wards and then you want to also add uh LORazepam because that will be an extra one to help reduce the, the manic symptoms. If a patient is already on treatment, then you want to optimize that treatment and sometimes adding new ones like mood stabilizers or E C T as well. So if they are a chronic bipolar patient, they will already be, or they should already be on a mood stabilizer or an antipsychotic depending on how young they were when they were diagnosed. If they are female or male and how they reacted to each of the um medications at the time of the episode or their diagnosis. Um CBT is also really useful. You can uh you can help the patient realize when they are tipping over into the hypomanic or mania or even in depression, they have warning signs and with, you can work with them in psychotherapy to help them be able to identify those and be able to seek help at that time rather than when they're already in full blown mania. Um And obviously social interventions like all the usual biopsychosocial model. Now, things to remember in terms of drugs is that um most of the mood stabilizers, stabilizers are also anti epileptics, um or things like lithium and these all have to teratogenic. So we usually tend to not give them in uh uh women of childbearing age. But also if they are thinking about getting pregnant and they're already on one of these, then they'll need to be switched. And if you are a female um with bipolar disease, bipolar effective disorder, it gives you a higher risk of peripheral psychosis as well. Um And this is just a summary slide for you guys um between depression and mania. Um Okay. So let's go back to the answer the question. So, what was the diagnosis for this patient? It's quite easy. Um um Two when they're pregnant, uh you would usually give the atypical antipsychotics. So like quite a pine and a land spine. Um an Arab put Brazil, Arab, but Brazil is usually the best like the least um side effects including uh late least cardiovascular risk. But I have to say I'm not a uh I'm not a mother and baby unit specialist. So I can't say specifically and I haven't been on one of those. So I don't have that experience, but it would be one of the antipsychotics rather than the mood stabilizers. Um Any other questions? Okay. What's the diagnosis for this patient? Yeah. Yes. So very obviously manic episode. And what investigations would you do for this patient? Mhm. Yep. So a urine drug screen would be my top one and then obviously just the usual bloods and physical examination. Now, how will you manage this patient? They, he doesn't have a background of any other mental health conditions. This is his first presentation. What would you give him to help manage him on the ward? Yeah. So uh manual. Yeah. So antipsychotic. Um and could and Benzos. So, LORazepam, um, if they did have a, uh, a past medical history of bipolar, what would you give him? Yes. So you could, you want to optimize his current medications? And then if he's on an antipsychotic, you can add a mood stabilizer if he's, um, already on both. And he's still, um, he's still presenting with mania. You can consider E C T, um, you can consider changing medication but always think about compliance. Most patient's once they start getting manic will or actually prefer being manic as opposed to depressed or even just euthymic. So they can not take their medication to help uh these symptoms. Now that that is a problem when you want to restart them on their usual medication because obviously, if they haven't been taken it and they usually on high doses, then you need to up titrate it back up again. Um or they can leave on depots which are I am injections of the um antipsychotic, which can last a month or a couple of weeks depending on which one you give. Um Now for this patient, uh he's becoming agitated and he wants to leave and he isn't any what, what can we do as doctors? Uh I'm happy someone said de escalation first before sectioning. Thank you, Virginia. So it always try the escalation techniques whether that's verbal or you can under the common law, give him things like I am medications. Now, if he still wants to leave and he is a risk to himself. We can detain him. Now, which um detention, which under which law can we detain him? Which section firstly, how was he brought into Edie? So he's brought in by police, which section do they use to bring patient's in? 136? Yeah, so section 136 is for police to bring anyone who's in a public space into a place of safety that can be any or it can be a specific, there'll be a room on any psych ward. Um That's the section 136 suite. Now a section 135 is when you take a patient out from a from there specific from the personal area. So their home um is usually uh the case for 135 and it's again a police power. What's the doctor's holding power? So 52 is the doctor's holding power and 54 is the nurses holding power. Now, these are very specific and the patient needs to have a named bed. So we can't do that in a any if they were, for example, on the ward, delirious trying to leave. But you know, they have steroid induced psychosis or delirium after uh operation, then we can use 52 or 54. So 54 is something that the nurses can fill out and it lasts six hours and a doctor has to come to see the patient. Uh five to um is a No, I've just forgotten. I think it's 12 hour. But if anyone knows if it's 24 that's, I think it's a 12 hour. Um, but 55 to um, is a holding power for doctors and it triggers the, um, sorry, 72 hours, 5 to 72 hour holding power. Um, and it triggers a mental health act. So if you a mental health Act assessment, so if you hold anyone under five to, then they should within 72 hours have a mental Health Act assessment where you carry out to either decide whether the patient can stay as an informal patient or whether you section them under section two or section three usually start with a section two which is 28 days and deciding um and it's kind of a uh to diagnose the patient. So you observe and you can start treatment and then section three is a six month holding power and um you use that as purely for treatment. Um and you can put patient's that have come in directly on section three if you know them and they are known to mental health services and you know what their presentation is otherwise, they usually start on section too because you always want to do the least restrictive section because you don't want to section someone forever. Does that make sense? Any questions about that? I know sections can be quite confusing. Okay. Um No, you can't, you can't do 52 in A and E. So in this case, he's under 136. So he can be held with restraint, um physical or chemical um and then you would trigger a section, a mental Health Act assessment to try and section him if he wasn't able to, if he just wasn't staying okay, any other questions? Okay. Last question. So I'll give you a minute. Yes. So um all patient's can refuse medication and this is where it's really important when you do your MSC to document capacity. And at the time, if the patient's refusing, the patient, remember, capacity is decision and time specific. So most patient's will have fluctuating capacity. So if at the time they're refusing medications and it also depends how they are admitted if they are an informal patient and they're refusing medications is because we deem them to have the capacity to except to understand with the and insight into their condition. So they're accepting help. Um, now if they refuse and they continuously refuse, then you have to reassess their capacity and try and understand why they're refusing. And then you can section them to give the medication under there against their will. If they're already under a section, then they can't refuse. The whole point of the section is that we can treat any uh mental health problems during the time that they have the section. So we can try different ways of giving the medication. Usually we try with de escalation techniques. So we asked them to take it, we offer it multiple times if they don't take oral medications we can consider. And we use this more in the elderly population covert medication. So you can dissolve it in a juice or you can put it in yogurt. Um And you can give it to them that way. Um If they're still, if we're not able to do those, then things like uh intra muscular injection, uh injections are the ones that we go for. So Depo's or um that some of them last only a day. Um Some of them last week, some of them last a month or three months. So we can titrate it because especially if they're under section too. Um Then we're still trying to figure out what's going on and we don't really want to give them a month long medication because say they've, they don't necessarily react well to that medication. We can't give them anything else for a month. So usually try and give them tablets because they're short acting any other questions. Okay. Um Did that answer your question? Marina? Yeah. Okay, perfect. Um So let's move on to anxiety. Um So anxiety is an umbrella term for multiple different conditions. So there's generalized anxiety disorder where you will have uh the patient will have continuous and generalized anxiety and there will be no specific trigger. So they can, they can be anxious for no specific reason and it lasts for a long time. Uh More than six months, phobias are kind of like generalized anxiety disorder, but it's for a specific trigger and it's usually with that specific trigger that they get this anxiety and it uh the avoidance makes it worse. Panic disorder is so intermittent panic attacks within a month with no obvious trigger. Um Now, anxiety has many symptoms and patient's can present in all different kinds of ways. So they can have psychological symptoms like poor concentration, irritability, um difficulty falling asleep, uh fears, worries. Um but they can also have tremors, headaches, um tinnitus, they can have stomach pains, indigestion, nausea, um chest tightness, palpitations, they can have uh feelings of restlessness. Um they can have urinary frequency. I think we've all been there before exams where we get all of these symptoms, um breathing difficulty, um all these, all these other symptoms. So anxiety can present very generically. Um Now, things to consider like always we want to think about are triangles. So think about other causes. Um Do they have hyperthyroidism? Do they drink a lot of caffeine? Now, that's really important. Do they have arrhythmia? So if they have um things like ectopics or if they haven't diagnosed wolf Parkinson white or SPT, then they will have these episodes of palpitations which they can confuse with um feelings of anxiety. So that's important to think about and substance misuse. So as always drugs, alcohol can cause all these symptoms, um especially withdrawal of those and then think about your other psych conditions and depression and anxiety can go hand in hand quite a lot. Um So that's something to think about. Okay. So as with all the other ones, it's exactly the same stuff that we do for all of them. Um And for this one, particularly E C G I think is quite important. And remember the electrolytes and TFTs because again, we want to think rule out organic causes first. Um Now management for each one. So for anxiety, you can use anxiolytics, um like benzos, especially if it's for an acute short period of time. So say they, they're very anxious about flying on a plane. You can give them a Benzo to take on the plane, but we don't like to use them the long term because they are very addictive. So we would use stuff like SSRI s again or SNRI if um to treat the anxiety. And CBT worked wonders for anxiety as well. So um CBT is always really important phobia as well. CBT is very targeted to phobias and you do something called exposure um to the trigger. So they'll start off with, I don't know if anyone has seen a CBT session, but you've got a kind of a a ladder and say you're scared of spiders. And so that the top of the ladder is touching a spider at the bottom of the ladder is don't know, thinking about spider. And so you every session you try and go up the ladder. So for this session, I'm going to think about spiders. The next session, I'm going to look at videos of spiders, the session after that, I'm going to trap a spider in a jar and just look at it from far away or get someone to trap it for me. Then the next one I'm going to like be in the same room with the spider, you know, and build it that way because it's the, it's the exposure um that will reduce the anxiety um over time for phobias and then panic disorder, CBT and SSRI S and if they're not improving after 12 weeks, then you add something called clomiPRAMINE and you can try other techniques like relaxation techniques and coping mechanisms. So PTSD um is kind of under the umbrella of anxiety, but it's, it's separate. Um It's specifically after uh an event that is this, that's threatening or catastrophic to the person. So it doesn't necessarily have to be a kind of tsunami or earthquake. It can be some, something specific to that person, um like a mugging or anything like that and they will have a delayed response to the event. And it usually begins within the, for this first six months from the event, they will have uh flashbacks, um nightmares. Um they'll have anhedonia, um Survivor's guilt and hyperarousal. So they'll have insomnia like we said, um hypervigilance and the way to um treat PTSD is usually to watch and wait, especially if it's been. It's quite soon after the event. After a month, then most people's presentation like this will kind of settle, the brain will, um, sort the, the feelings. But if not, then that's when it will trigger kind of the PTSD management where you want to use trauma focus CBT. Um, you can do EMDR. Uh So I movement, um I'm have meant I've forgotten what they mean. Uh, but it's therapy to basically you get the eyes to move like this or you tap on either side of the patient's legs or they tap either side and it helps with processing of memories. Um, group therapy is really important, especially to kind of uh, survivors of, uh, disasters or war zones and then you can use medications. Um, okay. So back to our questions. What was the answer to the first one? So, what's our diagnosis for this patient? Any ideas? Yeah. So panic disorder is correct. And how would you manage this patient in the acute setting? Yes. Good, Annabelle. So, um, 80 is always you're first approach and you want to rule out other causes. So in this case, they said that the chest is clear, her heart, her sats are normal. Um, although her heart rate is quite fast, um, this is most like to be just a panic attack, but you want to rule out that she's not having an asthma attack or that she might have a P or anything like that. So I want to rule out other organic causes and then we can give something like other as a pam or um something else. And then what about in the long term, what would be your long term treatment for this patient? Yeah. So CBT um SSRI s other coping strategies um breathing techniques as well. Um Yeah, good. Okay. So our last topic is OCD. Um So OCD is obsessions and compulsions is characterized by obsessions and compulsions. So, obsessions are basically uh recurrent intrusive thoughts um or images or impulses um usually about things like contamination or um infections um but can be about other things as well and then they'll have, they'll do a compulsion. So they'll feel like these intrusive thoughts will um the upset, the discomfort from the feelings of these intrusive thoughts will improve by them doing these rituals. So they can, I don't know, step over the threshold like 56 times, like open the door um or they can turn on and off a light switch 10, 20 times or they can wash their hands 10 times and this will help with the feelings um uh from the uh obsessions. And the key thing to remember is that OCD patient's usually have insight. Um They know that what they're doing is um is kind of not the norm, but for example, some of the obsessions that they might have is, I don't know a family member dying. The only way for their family member not to die is to turn on and off a light switch. So, for them it's just what turning on and off a light switch 10 times, it's not going to, um, affect them that much, but at least in their head they making sure that their family member stays alive. So the management is to do CBT. Um, usually, and we can use SSRI S which are second line actually. And you'd only use it if they have moderate to severe um OCD or OCD that's affecting their life in general. Um And then you can add clomiPRAMINE afterwards if the SSRI wasn't effective and you do a 12 week trial for the SSRI. Um and I forgot to mention actually, sorry um for depression and, and anxiety, you want to continue the, the SSRI S or the antidepressant for 6 to 12 months after the symptoms have improved because otherwise they can relapse. So I've got a couple of quick fire questions to finish off. Um So what monitoring do you guys think we should do with antipsychotics? Anyone? What treatment? Uh Sorry, what monitoring would you use? Yeah. So four blood tests, I agree. So prolactin is important. So LFTs using these HBA one C weight. Yeah. So, baseline E C G is important. Um BP as well. Now, what do we look and look for in the E C G when we prescribe antipsychotics? Yep. So Q T Q T C interval and uh most antipsychotics, apart from some of the atypicals, um prolong Q T C s. So, um you want to make sure that it's at a normal level before you start uh antipsychotics. Now, what specific, for specific um medications you want to do specific monitoring as well? So for lithium, you want to check lithium levels and you also want to do use the knees because lithium effect and anti FTS because lithium affects the kidneys and it affects the thyroid. Um but things like risperiDONE and actually quite a lot of the antipsychotics, we always check prolactin because most of them are dopamine um agonists. Uh um So they will cause um prolactin to rise and then HBA one C and lipids because most of the antipsychotics cause uh metabolic syndrome. Now, when starting SSRI s, what should you warn patient's about about? Oh, sorry, anyone. Yeah. And what else, what medical emergency can happen? Yep. So Serotonin Syndrome. So with SSRI S always make sure that you tell patient's that for two weeks, especially family members to watch out because it can, they can get worse before they get better. Um especially Children. Now, what is Serotonin syndrome? Does anyone know what, what presenting features will they have? Yes, they can have diarrhea. Yeah, exactly. So they'll have autonomic instability, um hyperactivity and altered mental status. So you want to look for those three. What's the other, um medical emergency. That can happen with, uh, antipsychotics. Yeah. NMS. And how does that one present? Yeah. Yeah. So, exactly. So, we, uh, that's fine. So, high fever, um, is high fever, high hyperreflexia rigidity, they'll have sweating. So, and it can happen at any point. Um, usually when you start a new antipsychotic but it can happen at any point during an antipsychotic or an antipsychotic increase. Um, so actually we do do baseline CKs in all our patient's when they're admitted because some people um can have raised CKs as a baseline. Um But at least that way you'll know if they present with NMS. They, they're CKs go way up, they go in like the tens of thousands. So you'll know when someone has NMS. Um okay. And last question, how long should you continue antidepressant treatment for? So you want to do 66 to 12 months after the remission of symptoms? So they can, they can be on antidepressants for a year or two, still having symptoms of depression. So you want to continue it until they have the remission of symptoms and then continue it for another six months at least? Okay. Um That's everything I had to ask. I had to teach you guys today. Um If anyone has any questions, I'm more than happy to answer them. Um Yeah, great. Yeah, just, just to reiterate if anyone's got any questions, sorry if my wife buys a little bit dodgy. But um I'll put the a link for the feedback and a QR code on the screen is the exposure response prevention therapy. Um Yes. Uh So it's the same, yeah, it's the same as for photophobia. So that's the one that we would use for phobia. Um You basically uh like I said, the bladder, so you slowly introduce um things that are similar to the phobia but not as bad in level because when you think about anxiety, it's a kind of like an exponential curve like a bell curve in a way. So um if you start off, you kind of start here at the bottom and then it slowly the anxiety rises when you represented with the stimulus. And then as as long as you sit with it, the anxiety will eventually come back down. So the exposure, exposure response prevention therapy will target reaching that plateau quicker so that you can go back to your normal unhygienic state. That's okay. Thanks guys. Good luck on your exams. Great. Yeah, thanks a lot, Doctor King. This lecture was amazing. I think really relating it to the cases and then bring it to the topic was really interesting. A new way of going about it and been thoroughly engaged throughout. So, thank you. Thank you very much. Um If anyone has any questions now or if you want to email, I'm more than happy for my email to go out as well. Um If they ask, so I'm, yeah, just let me know. Uh they don't have to be about psych. I'm more than happy to answer any other questions too, like uh foundation year stuff. Yes, I from that. Thank you very much everyone and we'll see you, see you next week. Thank you very much said. Thank you, everyone. Thanks.