Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Can I tend to talk quite quickly. So if I am and something's not clear, just stop me. I'd uh probably easiest if you just um you yourself and just tell me. Um because otherwise I am, if I'm sharing screen, I might not be able to see you um feel free to have your camera on as well. So I can see you if you're asking a question. If you are shy, that's fine by me to I know the feeling myself before I start just a bit of background about myself. So I, some of you might have met me before. I don't know, I can't see any of you. I've actually previously been an option guinea training for a few years up until like about S T four. And then I changed to psychiatry. So I have a bit of experience in medicine general, but more specifically opting Guinean psychiatry. So I, I do and so that's I think why get given the perinatal mental health section as well as schizophrenia eating disorder and legal aspect. Um If there is no burning question or anything that you guys want me to specifically cover if there is feel free to a mute, put in the chat. Now I'm gonna make a start so we don't lose any more time. Um I think the slides can be shared by med it after I have sent them, sorry this morning, which is quite late. I appreciate that. Um, but I was a play finishing them yesterday. Um So the slides themselves are a little bit information heavy. I tried as much as I can just do a summary of everything that I think is relevant and usually useful in your exam, both for the written and paces. Um But I'm might skip over things quite quickly and just to talk to you, uh I've been told to make it quite interactive. So hopefully that will work, but that will require your participation if you don't want to, I'll just speak and just listen to my own voice for about two hours. That's okay too. And anyway, so first of all, let's do the legal aspect because in my experience that tend to be left until the very end. And by that point, you're all exhausted and, and no one really want to pay attention. So I make the decision to start with it first. So this one, you should all know already met a Capacity Act 2005. I highlighted the main point which is basically everyone should assume to have capacity unless they are proven otherwise, no matter their age and uh wife of background, they have or demographic they have. Um And that means we have to take all necessary steps or practical practice, a ble steps to help the person. And I think the language is less inclusive back in the days. Um to help the person too, be assessed for the capacity and to be, you know, to be able to exercise that capacity, that in practice. What does it mean is if they speak a different language, they need to have interpreters if they are deaf or mute. And then we have to try to see, use the British sign language. Um And even if they have learning disability, we don't presume they have lacked capacity. We may have to find people who understand and know the person very, very well, which um sometimes in a psychiatric setting, um in order to see, um can we get a consenting, get assessment of their capacity and consenting process done? Uh If that can be done, then we need to do the best, best interest to make sure that we are acting according what is most beneficial for the person also, whatever decision we make has to be least restrictive. So once again, is in the best interest line. Now, the one of the most interesting thing I've told you guys, I've been previously an ob Songane trainees or I work up to a restaurant level, I think of money term. So sometimes just because someone's making unwise decision doesn't mean that they lack capacity So, for example, today on the ward, we have um, inpatient gentlemen, I currently work in a Picchu so psychiatry icu intensive care. Um, he's quite obese gentleman. I think his BM, I would be somewhere above 35. If not close to 40 he's on to antipsychotic, which unfortunately give him a lot of um, thigh effects of metabolic syndromes, weight gain. He himself used to like to have a drink, he really, really likes to drink his coke. We're trying to move him on to die coke. Now, there's a lot of question about rather or not, we can find ways to help, restrict his um cook or soft drink consumption because obviously is not good for his health. He is already on Metformin. Uh He's actually HBA one C is not bad, but he's only like about 40 years old. If he continued at this great, he's gonna cause a lot of issues in the long run. Uh The problem is he has capacity. Yes, he's in patient at the moment. He's under section. But in terms of the uh eating and drinking habits, he has capacity because they are very specifically task uh to each task or each thing. So for him, in the, in the circumstances of understanding what drinking soft drinks means to his health, he understands will push his blood sugar up. It may cause problems in the long run affects his diabetes. Um to die teaches answer maybe I just keep taking medication and follow up with my doctors. It'll be fine. Um, but what about your long term health plan is like, well, if I on medication I keep seeing my doctor, if there's any other things I needed to be adjusted, he can do that. But he really, really like his coke and he just want to continue his, it's as in his word is one. Enjoy. Okay. All right, bro. Hi. Am I back? Yes. Hi. I have my back. Yes. Ok. Sorry. How much did we miss? Uh nothing. I think it was just the last minute or so. Okay, great. So continuing on. So, so in this case, this person really understand the information which is having soft drink continually can affect his blood sugar and diabetes in me. Hello. Hi, Laura. Okay. That was any question that uh that's Laura is fine. If you want to speak, please do. Um So yeah, the case was the patient, understand what his diet for MS affecting him. He retain the information that he used the information to come to formulate a decision and communicated it back to us. It may not be the decision that we want to hear, but it's the decision that we have got and we have to honor that because he has capacity. So that is important because in the future you guys as F one, um I talked to all the medical students' this way. Unfortunately, I used to go to Imperial as Well, for your fifth year and six years, you are basically tested to be c to see, sorry, tested to see if you are fit enough and if you're safe enough to practice an F F one. So for F one sometime you may be expected to start doing consenting process. So that's why, you know, understanding what capacity means, how to access capacity is important. Um It's about getting the information, they retaining the information, using the information in that way to formulate a decision and then communicating back. So, um yeah, so that's basically what it is when we're using, it is for procedure, but there are can be unusual circumstances. I may have seen the hand up earlier on. Is that right? Or am I imagining things? Never mind? Okay. So um if you want to for uh you know, just um use an answer. So basically the S P A is there's a 15 year old girl of email coming to the G P practice wanting uh contraception prescription because she want to have sex with her boyfriend from who's from who she knows from school. What is the best part was the best action that you can do is it to one to assess the capacity prescribed the contraception? Because if the person has Gillick competence uh to explore the details about the current home circumstances, relationship with parents guardian, as well as her boyfriend, three offered to an appointment to see how her parents guardian to fully explore the risk and benefits of contraception for offered to have a separate appointment for her parents. Guardian to explain her wish for the prescription before prescribing and five just refuse. Go ahead. Anyone, any thoughts a a so assessed capacity uh and prescribe you Gillick competence. Do you mind me asking why Annabelle? Because you can give contraception if they are good at call impotent without informing parents. But ideally, you would have her encourage her to talk to her parents, but you can't force her to. Perfect. So we're coming back to the point where we have to do everything we can that's practice a ble to help them and guide them in the decision making for capacity, right? So you're very correct. And the 16, they asked you allowed to have to make their own decision and consenting for procedures in life threatening situation. They don't, they may not have the right to refuse treatment, but they have the capacity. They have the right for um consenting to treatment or consenting to a prescription if deemed necessary. So you are right in that unfortunately, it's not the most appropriate answer for this scenario. Can someone tell me why? Um Is it because she's under age? So you need to check that there's no um like you would probably go for number two, maybe just to explore more about the boyfriend. Perfect. Well, underage. Yes. Um You want to explore the circumstances a little bit more in general also because I kind of hide a little something in the, in the question, which sometimes we do, I help write some of the questions as well. So you do need to read every line mode. Everything that's been put into the question usually have a purpose for S pas we don't try to trick you, but the clues are usually they're so make sure you actually, at some time in exam, I, I come from the federal wage where my, my exam papers actually still paper. So I usually go around with highlight actually highlighting things that I think you may be relevant. Her boyfriend from school, there's no more detail. What's the age of the boyfriend? He said, uh it's a fellow classmate. Is it a teacher? Is a staff member? Exactly. Thank you, Laura. That's very good as well. Exactly what I'm saying. Also, at the same time, there's nothing in the question where they actually, she doesn't want the parents to know. We need to explore what the dynamic is. Maybe she's just not aware that she should tell to her parents. I mean, unlikely, but it's a fair thing to just find out. How was your relationship like, like with your parents? Why you may not want them to know? Is there something that I can do to help? So actually, once you explore the detail about all these things, but 13 and four can be possible can be appropriate. Obviously, if I change the question slightly saying that her boyfriend is only 15 as well, same age, same class. Does that no concern about risk, vulnerability, safeguarding issues? And she's very adamant that she doesn't want to tell her parents, despite you have attempted to convince her by offering to see her with her guardians together or to, um, see her guardians parents separately because remember sometimes teenagers don't want to be in those conversations themselves. So you have to offer both options. Despite those offer of help, they still say no, then yes. If they have daily competence, then by all means do prescribe. So 13 and four are reasonable, but only if you have more details. So two is the most correct answer for this 15. It's obviously wrong. You can't just refuse are right. Okay. So we said for for consenting process, you need to have sorry any question about that one. Anyone want to challenge me on my answer, you're you are welcome to by the way. Okay. I take that pause and silence. That's no for now. If you do just a mutant shoutout. Um So yeah, for a valid and informed consent, you need to have the person to have a capacity, you have assessed that um uh the decision needs to be informed. So you have to give full information. Um Again, this may not be less exam um orientated, but this is for kind of clinical practice. So that's why I'm helping on a little bit about this. This because one day someday, hopefully, soon you're gonna put your name on the dotted line for the content form, which by the way is actually not legal document. Um You know, those yellow a free paper, they're actually not legal documents that they're not like a contract. Um Those are documentation of the legal process that the consenting itself doesn't have to be written if it's verbal is still valid, can be uphold. Um by the way, sorry to digress a little bit. So, um the when you do the consenting, you need to make sure that the person have enough and sufficient amount of information. So not too much, not too little in a digestible manner. So no jargon, which is why we're harping on about it in communication skill, know jargon because they need to understand them. And also without coercion, meaning they have enough time to consider in the manner that you give the information, you haven't tried to sway them one way or another. Um There's no family members or are they party of the interest who are trying to sway that decision one way or another? So it has to be informed, has to be voluntary. Okay, sometimes it can get a bit tricky when the patient asks, what do you think? Then doctor? Um unfortunately, it's getting more and more common sometimes that we get asked these questions and consenting process. So that bit you will, it will slowly come in uh in your clinical practice and like want you some more time from this lecture to go into it. Um So under 16, we already gone through parent consent can be given if they don't want the parents to be involved with, assess, assess them to see if they're Gillick competence or if you can follow the fraser guidance. So, Gillick competence about competency of the person under the age of 16, Fraser guidance is the specific guidance uh done by the judge, I think um who are ruling on contraception and also giving prescription basically for under under 16. Okay. So if there's no capacity you act under best interest or the court's can decide lasting power of attorney advanced directives. I found the decision if they interested. I know I'm from Imperial. So sometime a bit of a nerd, I want to know where things come from. So these other section from M C A 22,005 just in case you want some bedtime reading or something moving quickly on if that's OK, going to go to MHA now. So the Mental Health Act which is from 1983 um there's about 10 different parts and again, if you want bedtime reading, amazing. Uh most specifically the ones that we really care about psychiatrist session two and three, which is from part to which is session too is a mission for assessment session, freeze for a, a mission for treatment. So let's say we have a patient coming in for assessment under MHA A under MHA. They can be self presented or you know, that comes in umbrella that they come in via um the G P referral A N G E um area as London ambulance service, um that company by friends and family, whatever it may be. And you think, oh, there may be a mental disorder than needing a further assessment of time for further assessment and treatment. Then you may go into mh A it may be because the person's remove, removed from public place. So either under section 135 or 136. So 13135 is basically a pre issued course warrant that the police can go up to the person's home frontal and remove them two places, place of safety. Um like in the hospital, I met a health unit 136 is if they're causing issues in a public place and the police are exercising their detaining power because they think the person may be at risk to themselves or other people or from other people, then they may be detained. 135. The ones that I've seen tend to be people who already have existing um mental health issues. Uh and they are discussed and organized by their community, mental health team or Home Truman team. So and so forth. 136, these are kind of your drunk people on Friday night who are causing disorderly. They may be people who are having suicidal attend, uh, that can get pulled down by the fire fireman or policemen and things like that. So these are the ones that get presented to any or the health place of safety in mental health unit or session run 36 weeks or H bus. Now, if they're already within the hospital, either they previously been presented to A and E for other reasons or um they are on a ward and they're causing problems and they think, oh, actually there may be mental health needing further assessment and treatment. Nurses can use 54, section 54 to hold patient which lasts above six hours or doctors can use 52. So these are the ones that you can exercise and I think as long as you're fully certified doctor, which means the F two and above you can use them. Yes, Laura. Hi. Um just a quick question about the section 136 can go up to 72 hours or is the maximum boy 24 hours. So section 13 sections only go up to 24 hours legally. Um There are special circumstances that if the person has been assessed. So the next part of this is you then have the mental health assessment. If then the person deemed detain herbal under mental Health Act, sometime if the bed cannot be identified or there's some unusual circumstances, then you can extend it to 72 hours. But that's like practice practicality when in the clinical practice for exam question. Remember 24 hours? Thank you. No problem at all. Yes. So some sometimes there are outside the rule things. But yeah, for, for exam purposes to remember 20 for what your senior told you in once your psych F one can be slightly different. Okay. So yeah, I've already gotten used to have so MHA a mental health access assessments by to section 12 approved doctors. So these are people who already have uh MRC psych exam and they are independent from each other. Those usually they're not from the same team. Um and also with an AMP as well approve mental health professional and they do the assessment together. So all three of them have to actually agree for the person to be detained if they don't see one of them say no or well, obviously, if three of them say no, then you can't detain the person and the person may not acquire emission. But even one of them say actually, I don't think this person should be detained, then the patient can be detained under MHA A. So that's actually quite good and fair system. Um So if they are not requiring a mission, like say the person coming because they were drunk on Friday night by Saturday morning, they so grew up have a bit of toast, they no longer at risk of themselves and other people from others and there's no existing mental health issues that you know, we need to deal with. Then we may say, okay, good. Now you're better, you can go home. Now, if they have an existing CMH T community mental health team, then we may refer them to them or if there is still other inputs needed, then you may want to refer to home treatment team, crisis team just like a holding team from the um in the interim until they get a little bit more stable or get seen by their CMH T. Uh Sometimes they are, they agree to informal emission. They may not meet the requirement for MHA section too, but they may meet the requirement. Actually, it may be safer for them to stay overnight or a few days in a safe place like hospital mental health unit. Then they may be a meta informally. Now, obviously, if they are admitted informally, they do have the power to self discharge. Um Otherwise, if they are deemed detain herbal, then go under 20 section to which lasted for 28 days. The person at the end of this 28 days can be discharged or this can be reassessed and go into section three which last for six months, which obviously can then be further extended. Uh during this 28 days, they have the right to appeal and then have a tribunal for this process. Uh Same during the section three is what they do have the power to have an appeal for tribunal. I think that's pretty much as much as you need to know for exam purposes unless you have had something differently. Um So the only other thing is uh in the informal admission. Um Again, this is more like a clinical practice question rather than anything else. Um If they do want to self discharge at that point, uh if you don't think it's a safe uh discharge, you can then reenact MHA assessment as well. But the way that you can do that as a junior is to hold uh hold the person in the hospital with 52 because let's say when I was a CT one, I was working with the uh West London Trust. That's this 20 something year old young chap who comes in has a background diagnosis of U P D emotionally unstable personality disorder. Um He came in because he was presenting with a lot of um self harm behavior, suicidal ideation but hasn't actually committed or plan any suicide at that point. But we recognized there sufficient risk. Um He's not on any medication, he's not overly drunk. There is no reason that he needs to be detained for Federer assessment for 28 days. But at the same time, it was recognized that he would benefit to have short stay in the hospital in the meantime. So he was informally admitted, I saw him as the night doctor, I think, and basically, he came to the ward and realizes quite loud, quite noisy. It's not the most pleasant um environment some time. Um And he want to go home, he feels better and also he has time to, you know, sober up, get better, stable, stabilize a little bit. But by then it's about 9 10 o'clock, which in the medical or surgical ward is not the best time to discharge anyone and also not um in the mental health units as well. So at that point, we'll say, uh actually I have to go and have a chat with him. Find out why is it, why he want to leave? It is something that I can do to help. Is there any way that we can make it a safe discharge for him despite the hours? So things like home treatment team, crisis team, sometimes I have 24 hours cover, depending on the location that you are in, then we can actually make a plan than we can discharge him and someone can see him overnight and then see, see him in the first in the morning as well. Unfortunately, that couldn't be done. So if he insisted to have a self discharge at a point, and we'll have to hold him for five to which would then um automatically trigger. Mhm. A again, within 72 hours, fortunately, this chap didn't require that he was reasonable. He understand the rationale behind it and he was great to stay overnight and was seen by his day team the day after. So that is a scenario why, why and how that may come into hand. I come in to use. Okay. I think that is all the legal aspect of psychiatry or maybe F one I'm gonna cover any questions so far. Okay. Five second silence. I will go on then let's quick chat about schizophrenia, psychotic disorder. So, psychosis, it's basically a derailment um from reality. So the person is not in touch or in keeping with the reality, obviously happens in psych uh schizophrenia psychotic presentation, but also in mood disorder. So you have effective disorders. You can see a mania invite bipolar or depression, schizoaffective disorder. We see it quite often in um stress or anxiety related disorders like PTSD bereavement is quite common as well in a bereavement period. Use hear people talk about hallucination to see their loved ones still alive or setting place is uh at the dinner table because they're joining or sometimes they can hear their loved one who passed away, talk, talk in the head that these are very common uh drug and alcohol related or for the obvious reason. And also in personality disorder as well, sometimes you have these quite vivid hallucinations or delusional belief that they can have that sometimes not completely shaka Ble. So um just a little bit about reality. So there's external and internal reality and obviously the person is not in keeping with either of them. Um But the importance about this is it means that the psychotic symptoms, hallucination delusion has to be um not in keeping with that own social cultural background. So, like whatever they kind of grew up believing in, if um if this newfound delusion hallucination is not in keeping with those belief, then that is the symptoms, let's say someone who's highly religious and has always been told that, you know, you're gonna be safe by whatever deity or God that you believe in um within that closed community. And then coming to another community, a society where actually that is not common believe, then it may be strange, but for that person, it is in keeping with the internal or previous external reality. So then that wouldn't be a delusional hallucination, um symptoms, schizophrenia, this slides little bit busier, but I kind of just put all the demographic epidemiology detail on that. Um So basically the person has really severe presentation where they are not in keeping or how have disturbed fart emotions, behavior is very long lasting effects, especially the younger that they are. The more difficult it tends to be um sometimes when the person is younger. So let's say the youngest person, I've seen any with any Skacel free near presentation is probably around 14 years old because if they're in that delicate stage where their personalities just forming their interaction there, um the communication to the external world just forming and the kind of consolidating a little bit more crystallizing a little bit more to their own personality. Sometimes we may not give the diagnosis. Schizophrenia as well. So you may have heard the term at at risk mental state used as well A R M S. Um So sometimes we use that term as well, but the earlier the presentation that usually the worst prognosis, it will be more likely to see, be seen in male at 1.4 to 1 uh female strong, you know, take predisposition. So you all always Moana Moana cycles, twins are most likely. But if they have both parents have schizophrenia or psychotic presentations, they 50% more likely to have schizophrenia diagnosis themselves. Um If they are living in the urban setting or they migrated to urban setting day more at risk, apparently, if you're born in the winters, bring you slightly higher risk as well. And obviously recreational drugs, especially cannabis. Um not quite, I don't think it's entire highly proven with the causality causality because there is under the school photo theory where people using cannabis because they're experiencing hallucination or psychotic symptoms. So they're using it to kind of self medicate, so to speak. But there are some sort of study who also found that the stronger the cannabis like skunk, they can sometimes cause psychotic symptoms as well. So these are the collections of the different symptoms for exam purposes. Just remember mesolimbic pathway. So these are the dopamine pathway they are, the mesolimbic pathway is associated with positive symptoms and music cortical pathway is associated with negative symptoms. So that's the main issue. Uh Sorry, the main thing that you can remember you, if you get asked that in Paces, then you've done really, really well. I wouldn't worry if you forget that answer. I don't think you will fail. Um, if you answer it, you may get very merit of distinction, but most likely they will come up in your s pas and things like that. Um The other thing is because they have, they are losing touch with the sense of reality very often. It means that they, the executive function is impact. So these are the things like your memory's attention, uh decision making. So on the ward that where I'm working at the moment, I see a lot of the time where patient's with schizophrenia um diagnosis, they, you tell them something like say they can't have their section 17 leave from the ward and half an hour later they will come back and ask you again. Now, there's every possibility because they're in mental health ward and they're bored and you just want to be annoying. Um It is possible but also sometimes because they don't have as a function as good a functioning um working memories. Um So they may just forget or they weren't paying attention when you're talking to them or when we were talking to them. So just have to better in mind. That is a common presentation as well. Uh They can have full disorder, they have negative symptoms, also disturbed behavior, uh, actually come back to that one in the second. Um, so pre drum phase just to be aware of that negative symptoms tend to come before the positive symptoms. So these are the bit that where they become more socially withdrawn, kind of like quotation a little bit weird. Uh, so these are the time period. Uh Yeah, if you, if you were able to detect them earlier, then you'll be better because there's a study showing that the longer the untreated psycho psycho psychosis period, the worst prognosis, it is so that there's a very strong incentive to diagnose them early, detect them early start treatment early. Unfortunately, the positive symptom tend to start a little bit later. So that's why what makes it difficult sometimes. Um I think you all seen session as R I C D 10 of 20 diagnostic criteria. So one of the following or two of the following, you can make the diagnosis of schizophrenia. I'm gonna spend much time on this because you can read and you can just remember that for exam, very unlikely they will give you a fresh schizophrenia case in case is um just because taking history and doing mental state on a schizophrenic patient for initial assessment most likely will exceed 78 minutes for your time. But in case you need to There you go and also it might come of SPS as well. So I thought I would ask you uh distance that which might not. Which one among sorry, there's one missing among the following is a good prognostic factor in schizophrenia. Is that one acute onset to deficit syndrome or persistent of negative symptoms, three longer duration of untreated psychosis for male sex. Five presence of neurological deficit. A thank you an any other guesses you are quite punished? Okay, fine. I push out your misery. A yes. So the more sudden onset acute onset, the better it is. Thank you care as well. Yes. So it is one or a um, so as I said, the longer insidious onset of um, uh, oh, they will, they are tend to be worse prognosis or the other ones actually, uh poorer prognostic indicators. Um, again, when I share the slides, I did a little paragraph at the bottom. So you can just read about it when you get the slides. So if you do get a schizophrenic schizophrenic presentation in your paces, make sure you do a full psychiatric assessment, but also physical health assessment as well. Just to make sure that there's no um, common bit physical health issues. Again, let's say diabetes or something, which is very common, um, that can get worse and with antipsychotic treatment. So that may be something that they put in unlikely but, you know, just to be aware of or it can be a good place where you can show off your knowledge a little bit. Just like, okay, I need to make sure that they are not diabetic because that might be worse than if I start on antipsychotic treatment. Cause usually that's one of the metabolic syndrome is one of the common side effects from those treatments or those medications. Um That's also why you need to monitor their B M I if they're on treatments, heart rate, BP, the usual. Um So, uh again, if they give you schizophrenic patient's for initial assessment, risk assessment in paces, most likely they will make everything else very, very simple, but you still need to make sure that you do a quick physical health assessment as well. Goes what I was saying, uh blood tests baseline for monitoring. Uh The way that I was taught is you can name any blood tests in the exam. Uh As long as you can justify it. Um FBC using U R T S. Everyone's saying uh sometimes not always applicable, especially impedes absent Ghani psych, not always applicable. The best get out of jail card is because I'm going to start treatment. I'm gonna start them on treatment or some sort of pharmacological treatment, especially in psychiatry. It's like a shopping medication they may affect um uh their baseline, how physical health markers. So we'll be good to have a baseline. So that's the line I've learned in my exam and it tends to work. So that's the reason why I usually give for FBC using your FTS uh lipids be again because it can cause more metabolic syndrome, dysfunction with antipsychotic HBA one C prolactin. Obviously, hyperprolactinemia can be affected because it's part of that opening pathway HIV, neurosyphilis can give you similar presentation to schizophrenia. We actually seen a case I think about a year ago in Hillingdon. So actually within our trust. Um So yeah, so you need to exclude them. Um Don't age, discriminate, sexual transmitted disease can happen once you're older than 55 60 years or as well. Actually, some of the more common S C I S are rising in incidence and prevalence in above sixties. I think, I believe. So, make sure you, you know, if there's any unusual presentation, make sure screen for these common at these significant things, creating kindness if they only if there's a significant saif uh side effect or complication with neuroleptic malignant syndrome. Uh Z G very important because above a sudden Q T C E level, you shouldn't start uh an antipsychotic. So just important urine drug screen for the obvious reason, imaging not always necessary. If there's head injury, history, trauma in history, then yes, by all means, otherwise it's not always necessary good. So there is a first generation, second generation medication typical Atypical I gave you the common ones that's in practice. And so these are the ones that you can name in exam. If your examiner asked you or wish, um, which class or like first generation, second, typically typical, then that's fine if they ask you what type of, uh, medication, things like that one. Again, you're doing very, very well. I wouldn't worry if you answer that wrong and to the examining maybe a little bit mean. Um, hello paradigm. We use quite a lot, can be used as a rapid tranquilizer as well. So that's very useful Fuko Pantech. So it's a older first generation medication which also come in a depo form. So they are quite useful as well as well. Cora promethazine, uh promethazine, promazine, we don't use as often nowadays, but you still see in certain practice every now and then they tend to be more effective on positive symptoms, but they're also more fun to give you side effects as well. Um On the second generation I give you kind of like a slight descending order, how commons of the side effects of arable. So usually have quite good side effect profile. Don't affect the metabolic um dysfunction that as much doesn't give as much weight gain and things like that or sexual dysfunction as much. But further down you go the list, the more likely they gonna give you those side effects closet being obviously a special case. So these are uh that is the drug that you use once you tried on two separate um and the psychotic for adequate dose uh for about 6 to 8 weeks. It's the Quenzel manner and one of them have to be a typical or second generation. If those still fell, the person have treatment resistant schizophrenia. So that's kind of like a buzzword um for SBA S or exam questions. Um Then you need to consider cross pain himself. Another atypical education, bigger trial shows that cause being can be more effective in those circumstances. Okay. So side effects, I think I'm just giving you a list. I'm not gonna go too much into details. Again, I think for your level for exam um S P A. Uh most of these things should be come up uh relatively easy for you to answer for pace is if you can name just that big headings, then it should be fine. Okay. Let's do some more interesting stuff which anti uh psychotics should be used with extreme caution and elderly patient with psychosis. Is it one episode? Sorry to clause been three a lesbian, four respiratory or five QUEtiapine same. Thank you care. Anyone else someone say hola a lancet pain to thank you man ish four Laura respiratory. Um Okay, so it's okay. I know. Oh, thank you. Um I know antipsychotic. It's confusing. I get annoyed or confused with them every now and then as well. Just because you know, you have to remember the typical atypical is difficult. Also they have very varied side effect profile if you see cause been as something mentioned about side effect just pay attention because cause being tend to give you the worst side effect. So going back to the last lied, um that is the one that has the highest risk of the blood disorder, neutropenia, angulos cytosis life thing. About about 1% of patient can get that. And it's not exactly those dependence, elderly tend to be less horrible with medication or more from to side side effect in general. So think about the population that you have, which is more prone to side effects and then think about which drug in the mix is the most risky, which is close pain. Then you have the answer that that is more a demonstration. You sometimes can education actually uh educated guess, make educated guess about these things. So look at the question is like, okay, clearly it's uh there's a uh from the book group here. So the question is really asking which one is the most, um which one is most likely to cause severe side effects? So that's why it caused me. Okay. Lovely. So otherwise you can do uh psychological intervention. So CBT for psychosis is actually quite getting more popular nowadays because there are often residual psychotic symptoms that you can't completely resolve because a lot of patient's find what happened with very high dose anti psychotic as they find can either be very heavily sedated or feeling the sense of numbness, emotionally blunt things or almost similar to some negative symptoms. And find it quite difficult. So actually, sometimes you talk to them uh in the long term plan, especially in the community, they may offer a slightly lower dose or antipsychotic where the symptoms doesn't, it's less disturbing. And what you can do is actually top up using CVT to help them to find ways or tools to deal with these psychotic symptoms. More um in a more culpable culpable manner in the, in the community cycle education, family therapy is very important in the community exp especially if they're young people. So not just under 18, but like even if they're in their twenties, because studies have shown that actually, if the family has higher expressed emotion, meaning like there's a lot of shouting, there's a lot of criticizing, there's a lot of it's your fault. There's a lot of um this is why you're having this, that it's that person's issues. Um uh you know, all these arguments in the family, they are more um the person with schizophrenia more likely to relapse if they in that environment as opposed to, you know, environment, that's not as high express emotion. So, psychoeducation is important to help the family to understand what it means, what the syndrome means. But also at the same time, it may be useful in uh in areas where there's high express emotion that is more like an MRC side question. So shouldn't come up in your paces. But who knows our therapy again, it's like a like a group setting most of the time is actually quite useful uh as well as compliance therapy if has any issues with medication as well. So that may come up in the S P A saying like that's a 35 year old, I don't know, 35 year old schizophrenic patient who responded well to OLANZapine in the past. But at the moment he is um he is not taking the medication day every day because there's some side effect issues that he doesn't like. Um, he's been to CGP does no major issues. Um At the moments, he's starting to have a little bit more psycho psychotic symptoms but not a risk to self others or from others. Um What treatment can you do? And compliance therapy? Maybe one of them and that can be an appropriate um answer as well. Ok. Social support, social reintegration is key, especially for long terms of finance, housing support, education, employment support, carers support. Those are important to. Okay. I think that was a very quick whistlestop talk of schizophrenia and psychosis. Any questions? Lovely. Ok. I know we want to push on and finish, but I had a long day. Um not feeling 100%. I'm sure you have had a long day as well. Can we take a six minute break and then we restart at seven o'clock? Is that okay? Yep, that should be fine. No worries. Perfect. Okay. See you at 67 o'clock. Okay. Let's find my place again. Yeah. So hopefully you're all back. We're doing well with time halfway through and called it with some time. So the next topic is para little mental health or perinatal psychiatry and anything to sort of. So we should finish within an hour won't be that long. So, obviously, perinatal psychiatry is anything that has, that happens in the antenatal period during birth and delivery as was postnatal period which some people extended up to in the service that I previously worked in. I was six months as a perineal mental essex showed and it can be extended up to a year, but some services are now considering to extend it up to two years. Um That service actually also um include a preconception clinic as well. So anyone who have um uh health disorder who is um uh female in uh who is considering pregnancy um then can be referred to that service as well, obviously subject to availability of time or in the borough if um so just kind of like your medical clinic as well or obstetric medical clinic. Um Preconception clinic is an option. Um So ASIO, she's Royal College of OB Songane has guidelines about care planning or your patient's things like that. I thought it's quite funny meme because actually it's true. So in your exam, you have to demonstrate that you're listening with your active listening, you are making high contact, you use open posture, you lean forward and you're nodding, your smiling. Um It is important because um again, from experience myself, as well as planning for exam, I used to help organize the paces as well. We use actors for 50 years, paces. Um Six years, usually it's real patient. But either case you want these people, you want those actors and the patient's to actually be on your side, you want them to like you. So actually if you are generally more interested and want to listen, I want to help, they will respond to that. So don't just walk in thinking this is the exam we need to pass. Also make sure that you don't, you know, try to make some friends, try to make a good impression of yourself because at the end of the exam, they will uh they will get given the question saying, oh if you see this student again, would you want them to be a doctor? Would you see this person again? And if they say no, sometimes it can be a heartfelt for you as well. So no pressure, but just be a normal cheerful, nice self, then you'll be fine. Okay. So um just learn your medical issues in pregnancy. Any and they are common. They anything that's existing is more likely to get exacerbators. So things like anxiety is very incredibly common. I think there's some study showing that actually anxiety most likely have most often happen in the first two trimester and actually got better over time was depressive symptoms, which is another big presentation usually start getting worse in the second trimester into third trimester and then also continue postnatally. So both are extremely common. If their existing mental health issues, you need to be aware, the family uh partner, they all need to be involved in the care plan as well. So go off of it if you get perinatal mental health station, that's so so important. You need to involve the partner, you need to involve the family, the midwifed MDT. So these are your really strong buzzword. So high risk group, I think you all know this. So again, I'm just using slides, you can have them afterwards. Anyone who have history of bipolar schizophrenia, they're more likely to develop purpura psychosis. So you just need to be aware. Um if they already have anxiety depression, they're more likely to have those worsen during pregnancy or developing to postnatal depression, uh previous episodes or serious um postpartum or per uh mental health issues. They're more likely to recur things that is happening past, likely to happen again. Uh If they're complex, if they're on complex uh psychotropic medication regime, they're more likely to deteriorate cause more likely to suggest that their treatment resistant or there's a compliance issue or the pathology is more severe in general that they're more likely to deteriorate when there's a delicate time where there's a lot of hormonal balance, uh imbalance, there's a lot of physical and also psychological changes as well. Pregnancy in generals can be a stressful time for most people. Um consider for any first degree relatives who have bipolar disorder paro psychosis, especially under, well, especially on the female um family member for bipolar disorder purpura psychosis. Of course, only female family members uh any evidence of mood disturbance during pregnancy and postpartum period, then what to predispose again, previous period of inpatient mental health care again, kind of similar to your asthma um case history. If they previously been into I T U before, then you have this patient kind of should you know, have some red flag showing that you're more likely to need to escalate their care to senior level or two other teams rather than you can just see them yourself. So similar principle. Uh I made a little table before about the three most common baby blue uh peppery mental health or the ones that you're more like most likely get examined on. Um It doesn't include things like anxiety disorder, OCD. Um U P D haven't included those, but these are the ones that you're most likely to get examined on. So baby blues, very, very, very common reason being I think it's suggested diet is because there's a hormonal uh imbalance very soon after delivery of the baby, the birth baby. So during pregnancy, there's lots and lots of hormones raging inside a woman's body. So HCG progesterone preparing for the body to maintain the placenta, helping the baby to develop, preparing the woman's body towards birth, so and so forth. So these are all normal changes straight after the baby has been born and the placenta is delivered the progesterone. And also the question will drop quite significantly. So only two other times that really happens in a woman's life cycle. It's either in puberty when you know their baseline progesterone or estrogen are lower because they haven't hit puberty yet. Sort of pre pubertal. Uh The other periods were similar sudden changes is menopause. So these are the period why where potentially can have more mental disturbance. Fortunately, person italy is only quite short lives of 3 to 5 days, sometimes can last about 22 weeks. But these are things that is like being more tearful, emotional feeling sometimes can be irrational. Um uh but they tend to get better on their own. I think I'm, I've seen a hand up earlier on. It's not right. All ok person, native depression, common 10 15%. So that's relatively common. Uh usually happen within the first six weeks, up until our year person natively or post Parton Lee. Uh That's a question if you developed like 3 to 6 months after the pregnancy or persisting after that long, is it actually an underlying depressive disorder or depression that's been picked up during this person aged period? So sometimes that changes that diagnosis again, not very exam orientated. That's more like a clinical practice and also for the senior to decide that's something to consider. Um your presentation is similar to your uh normal, non pregnant and non perinatal depression as well. So the core symptoms or the other symptoms as well, I'm not going to repeat them here. Now, you should all know them or you can find those out easily. Uh Again, we're given the predisposing factor in the past, you're going to get this diagram so you can entertain however you want your heart desire, uh prepare a psychosis. Thankfully, it's relatively rare 9.2%. So when I was a medical student, I've been told usually happen within the first two weeks, the 10 years, I've been a doctor where almost four years as an option. Connie training and six months in paranoid Mintel, most of these kids happened in the first few days, usually, yeah, usually within the first few days, within the first week, usually see them. Um But it's been given that it can happen any time during or after pregnancy. So that's the time frame you've been given most commonly, we see them within the first week, post part and or um and up close to birth time in antenatal period. Um So that is the time frame that I personally have seen. They can have mania, they can have depression, they can be very confused, their hallucination delusion. So most important. So these are the high risk factors that we have mentioned before. Not going to repeat. Now, this is the perinatal risk assessment that I've used when I was uh as a chewing that team. So if it does come up in your exam, this can be the assessment that you use. Obviously, you can do your standard, risk yourself, risk to others, risk from others. So you check for all these general things, a specific question that you want to ask. Have they ever done any harmful, potentially helpful acts to themselves? In the past? I have to consider these before. Any delusion or our value ideas or hallucination involving the babies or Children. Sometimes they may think, oh my baby is the spawn of Satan or my baby is sent from God as an angel or my baby don't need to eat because my baby is a super person and never need to eat. So if there's any overvalue idea, delusion, that's unshakeable or hallucination involving the baby or other Children because they may have more than one then significant. Any thought plan in tension to harm the unborn baby or born baby and Children again, very, very significant. So in your harms to other, most importantly, is baby. Also, I usually ask about the partner as well because um they can have existing relationship strain. Yes, pregnant women themselves can have higher risk to be sub subject of domestic violence, but sometimes they can also become more risky towards their own partners. Well, just because of the relationship strain, so it is also in my practice that I usually ask hostility, irritability to unborn baby, other Children following from the last one, any concerns about any other person who may pose a risk to unborn baby or other children's. Again, this may be partner people in the community. Um Anyone that's around the care of this person as well as baby or babies, uh thoughts of behavior about extra estrangement from the baby or inadequacy as a parent, which is actually very common. Um belief. Most first time mom are very, very anxious and they may feel that they're not up to the job, they're not feeling most confident, but most of them are. Most of these beliefs are not unshakeable if they, if you then say okay, why don't we support you in this way? We can introduce you to this mother baby group. Have you read this burg? And that's this website or app that can help. They usually will get better that the ones that we're talking about here is usually the one that is unshakeable. Then that's a more concerning uh presentation. OK, Sina gave us six days ago. This is a second, a second child and this pregnancy has issues with gestation, diabetes picked up in uh you know, routine screening time. Uh the second stage of the labor was delay. Maybe it's because as big baby, I haven't given that information as a sister with operative delivery, which was not in seen as birth plan over the last two days. She's been constantly tearful, resentful towards the partner who has to go back to job. She otherwise bonded. Well, the baby breastfeeding, what is the most likely uh appropriate screening tool to be used? So there's five options. Uh Any tickets? Jack, I saw your question. I'll answer that in a second. Two, 22222. Good. Yes. Adding bread, postnatal depression scale. Good. It's in the name sometimes. I think they can be mean and give you the abbreviation. I don't think they should, they are allowed to, but sometimes they may be able to. So that's why um just remember having a person Natal depression scale and if it's shopping acronym something that's out, he, I think that's the only one that usually that would be okay. So I'm giving you example. You're absolutely right. It's to Edinburgh postnatal depression scale and that is quite sensitive, quite useful, quite easy to use. You can use that in G P. You can use that on the person eight award. You can use it in the community. If let's say this community midwife, the patient help question it is good as well, but it's slightly more general is less about the effective um uh symptoms. So that's why um Edinburgh scale is more, more likely to be this one because this one predominantly depressive symptoms. So that's why you want to be more targeted if it's slightly more diffuse to gen generally and well, more vague about symptoms you may want to consider PHQ nine. Okay. Let's have. Oh, Laura just asking what person aged period and I E would you go back to PHQ nine for assessment? I would say within the first 3 to 6 months? Definitely use the Edinburgh postnatal depression scale. Um from a service organization point of view, we see women up to one year, post postpartum again, some service extended two years. So that kind of give you a time frame, how long you can use these scales. Um I would say it's not a very hard and fast through because obviously, if the person start feeling a little bit depressed very soon after the birth of the baby, but not quite meeting um clinical criterias. But over time, over the next few months get gradually getting worse and worse and worse and worse. And by six months you, she managed to get the G P appointments. I will be very happy for the person to use Edinburgh postnatal depression scale. Um However, if the person was that they've lived with the baby, have baby blues for a few days, but actually was fine. And um next 23 months, there's absolutely no problem. But by month for suddenly there's an issues or let's say there's a bereavement, the family or they got sacked by the company or that company actually, or their partner got sacked by company, then actually, it may be a separate issue and you may want to use another scale that is less specific to postnatal. Does that make sense? Um Usually if there is symptoms, symptomatology, the PHQ nine should also be able to pick up the symptoms as well. So, postdate Edinburgh scale is more specific to uh post natal period. Um So that's why that's usually the one that we quote and we like to use. Uh okay, going back to Jack's question before I move on, how would be best to inquire about if the belief is unshakable or not? How does one actually phrase that question? Uh check, do you mind just to help me? Do you mean in general or is it specific to perinatal mental health to what I was saying earlier on? Um I think, I think I, I struggle with it in general as well just in particular to perinatal mental health. So I think a bit of advice on both would be useful. Okay. So if I tell you now, um I'm actually Jesus reincarnated, I come to you. I can walk on water. I can turn water into wine. How would you? So I, I just declared I'm actually think I'm Jesus. I can't walk on water. I swim, I can't walk on water. I can't turn water into wine. How would you test if my belief or delusion is shake a bill or not? Um I mean, obviously, I could say like, is, is that something like you just believe or do you think you can physically do that or is that? I don't know whether that would, I can do it? I'm telling you I can do it. Give me a pool, I can show you I've got other than getting them a pool to see if they can do it. I've got really no idea. Okay. So you can ask the person you can ask me. Um, how do you know that? How do you know your Jesus reincarnated? Because I have some information about you say, like the name on my screen, your your name showing up Stanford Wong. What, how did you know your Jesus incarnated? Um How, how do you know that your, you can actually walk on water? Have you done it before in the past? Have you shown people or have someone told you that in the past? Um Is it possible that it may be false information because sometimes you may be the case that let's just say um okay, I'm going to stop using religious belief because that might not be the most sensitive, let's lay, let's say political delusions. Like I'm a very, very powerful politician or I'm very, very famous celebrity is like, well, actually, I've never heard of you. Maybe it's my ignorance. But is it possible that maybe you're actually not celebrity or you're not important political figure figure? And is that possible? So you can ask that in quite nonconfrontational way you don't go into them is like, no, that's not true. You are definitely not easy. You're definitely not famous, you're definitely not celebrity. But it's like, is it a possibility? Does that make sense? Yeah, that does. I think it's a much better way of phrasing it. That actually clarifies it because I've been wondering that quite a while. So, thank you. Ok. No problem. I'm glad. Well, hopefully if nothing else you take one thing away from tonight, That will be very, very good. I'm glad. Um Good. So management, apparently I meant to have, I know scary. I had a much busier slide or, but busier freeze lied and then I decided to change it a little bit. So most of the time you're going to get asked about, it's probably antidepressant. Most likely you're not going to be asked to make the decision on antipsychotics as long as you say that the person may have prepare a psychosis and the antipsychotic. That should be enough. But just in case. So antidepressant, we use mostly SSRI in perinatal mental setting. So the ones that you need to remember sexually sexually has the best um, side effect profile both during antenatal period and postnatal period. There are a lot of fine prints. You, if you're really interesting perinatal mental health, we can have a chat and we can talk about it afterwards for your exams. Just remember sexually, you use a moderate severe depression uh in parent interment. Have you tried to use CBT. It may be an eye app. It maybe like in independent sorry, individual assessed CBT rather than group CBT or 1 to 1 C P T U. Use that in a mild, mild severity but anything moderate severe you can consider starting sexually. So that's the one that you remember. Uh, you use that for anxiety disorder as well. I think that's pretty much as much as you need to know, antipsychotic medication, preferably the lancet fine. Sometimes we use quit typing, especially if the sleep problems. Just to remember, lithium can be used the ones that you need to avoid. CarBAMazepine and sodium power pract. That's it. Okay. Counseling CBD the usual if there's any self harm behavior, DVTs a dialectic behavioural therapy, it can be useful. So DBT is kind of like a buzzword if there is any personality disorder, if their self harm behavior, DBT has been shown with much better efficacy for self harm behavior, suicidal ideation. So just remember that growth therapy activity can be good because supportive social support or just remember, you can offer information leave, let you can send the website. I included these because you guys are young and healthy. Maybe you need them some day. So let's just put them there. Um Bumps is very useful. It's the best use of medicine in pregnancy. So if you are rotating through a single tiny, if you're rotating to psychiatry, not just as medical student, but as F one F two or in your future career choices. It's a very good website that we actually routinely use. Ok, SBA for perinatal mental health, which one of the following is best recommended treatment option for pregnant women or female who is known to have opiate dependency and is already stable on replacement therapy with methadone. Is that one? Continuing with the methadone to stopping methadone gradually. Uh three, switching to buprenorphine which is a partial agonist. Uh and four switching to codeine which is a week opiates or five, switching to know Treksohn, 12345, which one maybe come on guys. No one, no guesses. I promise I won't tell you off. I'll go for answer one one. Why? Jack? Thank you for being so brave. Thank you. Why? Okay. I just, I just presume that, that they get the pen. So I presume, you know, they, they're not wanting to go sort of cold turkey and if the woman starts using sort of heroin or anything while she is pregnant, that's going to be much greater risk to her and the baby. So therefore, it's probably better to keep her on unknown quantity which women are normally kept on. Um Despite the risk of teratogenicity to the child. Yeah, but what about the baby? Why can't we stop methadone gradually? So the patient will go to cold turkey or switch to a different agent because there's an a massive depending on what the woman actually wants to do And I think if, if you're saying opiate dependence disorder, it's like, I suppose they could, they could completely cold Turk and do it. But I don't know whether this SBA is implying that I might be wrong. A lot of women. Sorry, I'm now grilling a little bit. I do apologize. You can stop if you want to actually in clinical practice a lot of women during pregnancy, they don't want to take medication. So it's not uncommon that they want to get off the medication. But in this SBA I say recommend the treatments are medically recommend the treatment. So from your point of view, if your patient's wanting to stop treatment but already stable on something, what should you do? So again, this is another principle s be a which I think may actually come up in U S P. I don't think it's an unfair question. So just remember most treatment can be continuing pregnancy in the antenatal person. It'll period because during pregnancy, there is two patient's not just the baby, but also the woman themselves. So the mother really need to maintain her health, physical mental in order to be able to one carry the baby well and actually allow the baby to continue to grow and develop, but also have the capacity to careful baby once the baby is born. So yes, most medication can have an effect effect on the baby. Methadone can have effect on baby. But if that is the medication that the mother is most stable on switching during pregnancy is not advantageous. So, Jack, you're absolutely right. I wouldn't go switch to buprenorphine or codeine or when Naltrexone is not a right option anyway, so that's just wrong. Um, or stopping medication. If they really, really, really want to get off the medication, we will make a very safe plan but also make very safe documentation that my medical recommendations for the person to stay on methadone because there's something to get them to be stable on because just like you, the reason that you get what I don't risk is for them to have a relapse during pregnancy, which will actually means even worse complication for the baby. So that would be the line of reasoning. Okay, same for other medical issues as well. Most medication like or medical conditions like asthma, things like that you continue the same medication. There are a few medications that, that you might to switch like a heart medication, things like that. But usually you will not get asked at this level because that will be just really, really, really me. I mean, even for imperial standard. Okay, that's it for perinatal mental health. Is that okay? Any questions take that as a no eating disorder? Let's start with the SBA Ryan is a 33 year old man. Yes, that's it. Eating a large volume of food daily for the last year. He hides his excessive eating from his partner. For a few terrible afterwards. For regret. He thinks about making himself form it to remove the food but has never done so he find it hard to stop the behavior that's by wishing to occasionally he restrict his eating to normal amounts of day. But this usually doesn't last. He never used laxative or exercise excessively. What is the most likely diagnosis? Is it one a typical ana rosa as, or anorexia, nervosa uh, to avoid and restrictive food intake disorder? A Aref I think binge eating disorder bulimia or other specific uh specified feeding and eating disorder free. Thank you, Jay Bussi. Thank you Annabelle free. Okay. So everyone's going for free. So I think when, so this is actually not written by me. I I thought it's just the interesting question. I think when when the person started writing this question that they were thinking about bulimia because bulimia has a strong obsession fixation about food, they unable to stop, they have excessive eating but they would feel terrible and guilty afterwards. However, Bolym a usually have a accompanying features of using something to kind of self purge yourself vomit, they usually have longer period of restrictions. They usually have um like more protein, more problematical the mechanism. So I think looking at this question, looking at the level of dysfunction, meaning like how they then cope with it and what problems is causing. I agree with everyone. This is a binge eating disorder that will be the diagnosis I gave um a typical uh anorexia is basically kind of like anorexia, but atypical. So usually I'll go into anorexia later. But usually there's one or two feature that doesn't quite fit. But everything else for in anorexia, this is not anorexia features. I think everyone got that. So let's leave up. So, eating disorder is fascinating, really, really fascinating because it's both mental health and physical health issues. Again, I think it will be fair if I mean to put this in the exam. But apparently it has happened before. The reason why I think it's mean is, well, I think it's a great exam question because this joint station it can happen in apparent um uh primary care setting. It can happen in a psychiatry setting can happen in camps, which is pediatric psychiatry setting. However, in uh eating disorder, you need to do both physical and mental health screening and assessment. So that's why I think for 15 minutes, it can be quite a lot uh similarly to hyperemesis as well, which again, I think it's very mean exam question but can apparently show up. So eating disorder in clinical practice is never just about the food and weight. Um Those are the things that you see like an iceberg at the tip of an iceberg. You see uh sometimes about confidence issue, a lot of the time they associated a personality disorder or perfectionism. Uh they may be depressed anxiety using as a coping mechanism as well as for PS PTSD. So these are the things that kind of have to consider. And the consideration is also are these comorbidities because they are very, very commonly seen as comorbidities as well. So if in a psychiatric assessment, it is important to screen for effective disorder anxiety disorder as well as any personality disorders are kind of like their relationship. Attachments type anorexia, nervosa are slightly more common, still very rare lifetime prevalence between 2 to 4. Most of the time is female peak, Asia's younger than bulimia in comparison. So there are usually around 15 to 19, they're younger. So previously, there was a suggestion that is in a higher socioeconomic group, but I think more and more study option. That's actually not true. It's across all social classes but tend to be with people who have a slightly higher educational attainment. People previously think it may be associated with a culture um phenomenon as well. I think you guys maybe a bit too young to remember when Diana Princess Diana um kind of discuss about her own struggle, mental health and eating issues. Um apparently then there was a lot of media coverage about how that's kind of spiked eating this disorder um kind of pandemic, but that's not true. It has always been about the sim similar preference. That's always been the case bulimia is slightly more rare. So less than 1 to 2% peak ages older. So it can happen between 15 to 25 years old, also still commonly female and across all socioeconomic setting and the rexy A needs to satisfy. So this is I C D 10 diagnostic criteria guys. Um B M I less than 17.5 or that is uh at least 15% below the expected um weight either lost quite recently or has never achieved that much. Um weight loss or so. Um weight loss is self induced. Um That should be breaking the sentence or about uh and body image distortions, they may look into the mirror thinking that they have very fat still just by the B M I have been quite low. There's a wild spread and the chronological dysfunction. So they might have, excuse me. Um They have uh uh the range TF TSH um fire function test la uh fire function level, high growth hormone, high cortisol levels because their bodies constant stress. Um despite the fact that they may have a stunt of puberty if they are prepubertal. So, uh and also most commonly uh in female, they may present with oligomenorrhea. So they have very scanty period or amenorrhea or e mails where they can, their libido can be affected. So, atypical anorexia, nervosa, usually the ones that I've seen the exam question, they will say their B M I is low, they have way lost their self. Um weight loss, self-induced their body image distortion, but they have no period. Then those are the ones that are usually is atypical anorexia, nervosa. So that's usually the exam question. I've seen um minimization of seriousness. So they try to hide the behavior. There's two type restrictive bench definitely need more than that. Give you just a diagram on or how it can affect the body. So it's both is across all that different as organ system. So again, I don't think we need to go to, to, to, to much the ones that you need to think about, especially in um exam setting because just in case it actually does come up in paces, think about mental health, how the mood anxiety, maybe like maybe memory concentration, attention, any palpitation. Because again, that is very important uh exam pains in generals, how the digestion's which I think you will be talking about already if you ask them about mealtime bowel habits and things like that on a physical how sign you may say you may want to. Yeah uh go into assessment the second actually um not come back to that. Uh Yeah, so jumping forward for assessment, um physical health assessment, you want to do the height weight B M. My calculation for the obvious reason also document the trend of uh weight loss. If there's anything between not 0.5 to 1 kg per week is significant, more than 1 kg per week is really significant. Maybe needing to admission blood test. Again, similar protests from earlier on calcium phosphate. Um uh especially important just in case they are below certain ways and you need to start feeding them revealing syndrome. You need want uh the calcium phosphate. So that's why it's specific for um eating disorder. Uh anorexia, especially E C G again, just in case there's a arrhythmia bone density scan because they may have osteo osteopenia, osteoporosis, early onset. So in your paces, talk through the meal, uh food habits. So again, how you ask that question is like, well, just tell me on the average day, what do you eat? Like, what time do you get up when you get up? How long would you wait until you have your first meal where you typically have, um, the reason I'm showing you more leading question is because they typically present with hiding what they, what they are eating and they don't want to disclose. So if you just ask, oh, just tell me, what's your eating habit? Like they would just say, oh, yes, normal. Okay. Oh, well, do you mind telling me a little bit more, um, like what time do you get up? How long do you wait until your first meal? What usually have? How about? And then when's the next meal? Do snack in between? Okay. What's the next meal then, or? When's your last meal? What do you have? What's your portion like? Do you actually finish everything off the plate? So you kind of really just find out as much as you can about the eating habit. Yes, we'll talk about, we'll talk about the three million second Laura. We'll get that. Uh, any compensate ori behaviors are like these are your vomiting, purging. Um, any use of laxative direct IX things like that. Or weight lost tablets or appetizer, supply suppressant, sorry. Uh, changing weight, any fear of weight gains, what the way, what does weight gain means to them? Sometimes they may put, um, a gymnast or ballerina in the station and say, oh, that means that I won't get into the body shape that's required. Um But again, that would be very meaning an exam but it may happen. How does it look to? Um what does it look? How does it feel when you look into the mirror, any physical symptoms? We've gone through that earlier on other mental health presentation as well as social history stressor. So sometimes it can be ex exam stress related. Again, remember the peak h uh from 15 years old. So like around the time of GCSE A level, is it related? Um Parental separation can be another big one that we see uh in this age group as well. So just think about all these things that potentially can happen. Uh Laura, I haven't without your question, we'll get there. Uh just going back to anorexia. Uh It's a gene general environment interaction uh kind of model with multi factorial threshold model. So it's not just one thing that can set of, it's usually multiple thing uh in a person who's already predisposed to this mental health presentation on mental health and physical health presentation, genetic contributions high and they are more likely to have a temperament of LCD profession ist and that anything that happened during the development growth, maybe physically, maybe um socially, maybe, culturally, maybe psychologically, uh that can cause issues. Again, symptoms of kind of budding personality disorder because remember personality disorder, you don't develop until you are, you don't get diagnosed until you are around the age of 25. But sometimes they're already presenting some traits of personality disorder P D. Uh average on average um anorexia last for about six years. But we're very high mortality about 5.6 per decades. Usually some a lot of times by suicide as well and as well as other uh morbidity and mortality. So just to be aware of that in general, I don't think you get us a lot of a prognosis. In example, good to be aware of bulimia we talked about already. So there's preoccupation with the eating in resistible craving food attempt to counteract. Uh So there are usually some action that they've done in order to kind of push themselves off the fattening food that they have consumed. And there's often a period uh sorry episode of anorexia in the previous time as well. So a lot of the time we see bulimia in an older age group when they have a history of anorexia when they were younger kids. Obviously you have to check out the differential diagnosis. Uh Upper gi issues presently disorder, depressive disorder can be the case as well. It's just going shows how everything is kind of related. Um uh Yeah, I think that's enough set. Okay. SB Kaya is a 19 year old girl brought in by her mother to the G P concern about odd eating habit, which screening questionnaire should be used. It's accorded Hornos Marzipan Scoff or sweet. Thank you of your mom saying four. Scoff. Yeah, because they're four as well. Any other takers any? Mhm. So uh then it stops, you know, do sharing. So all this is for alcohol uh Justine a say free, no problem. Uh Order said is for alcohol harness is a general health question there, Marzipan, you're, you're right is related to eating disorder. But that is actually the guideline. That's actually the most plan guideline is how for a recommendation for clinician to manage eating disorder. Skoff is the question there, I think is something about control eating. How often you did use other measure to lose weight and things like that again, in the uh discussion that's uh in on the slide I'll send to you that I put a paragraph that we can read about that. Sweet. I think it's just a made up one. I couldn't find one. Um That's actually acronym. The sweet. Nothing anyone have made the acronym just yet. Okay, answering. Thank you for participation for answering Laura's question now, which is in adults with anorexia is the first line therapy CBT or DBT. Considering it could be combined with obsessive compulsive personality disorder. Okay. So CBT and DBT are different in the sense that DBT is more effective usually for self harm, ideation, suicidal suicide reality. CBT is more for um I often think of it as like tools giving. So people who have Malko Ping mechanism, they have issues with um certain behavior of thinking pattern. They can, they typically go into like a vicious cycle that typically is better with CBT. So obviously, you can see that pattern can come into society, reality and self harm ideation as well. But that is much better with DBT was audio, the problems that you can think about small CBT. So if the problem's anorexia, CB um sorry, if the problem is eating disorder, the CBT is more useful, obviously beat is more useful in bulimia compared to anorexia in general. So that's why I changed my wedding and just say eating disorder in general, CBT is better clinical practice. CBT is most likely more commonly recommended for bulimia itself. If there's obsessive compulsive personality, depending on the presentation, I will also recommend CBT. Unless there's a lot of cell phone behavior in the O C Personality Disorder CBT property is more useful than DBT. Does that answer your question, Laura? Yeah, thank you. No problem. Okay. So again, because it's early presentation, family therapy, psychoeducation can be important. Biological, tend not to be that useful unless they're also presenting with depressive symptoms and anxiety symptoms. But SSRI can be used if those are present. Uh There's a medication called Matassa Pine, just be a bit more aware of that. One, I think is a higher level question. But I think it's interesting, Matassa Peon usually have a side effect of increasing appetite and increasing sleep, especially in low dose. So psychiatrists quite like using that because obviously these are the biological symptoms of depressed depression, Matassa pain where to be a little bit more carefully eating disorder, especially in someone already have body image issues, struggling with the appetite and eating habits. We don't want to use something that can affect that even more. So just to point that out, um not the Vitami electrolytes a replacement, something that dialyze which you will have heard of from peace can be useful as replacement or like a risk management. Uh Social is very important for school education also done by specialist E D team. So I think that's pretty much for your management than in exam, be aware of riff eating syndrome. Uh If you again, if you get to that question in pace, then you've done really, really well. I wouldn't worry at all if you uh it's usually more common to be seen in um SBA. Anyway. So these are the picture that has low phosphate low magnesium, potassium, fine mean they retain a lot water that has a big present with faint weakness, confusion, high BP seizure of mere heart failure. That's why it's very important. So especially in the SPS, a person who can present with BMS 15 to 16 medically unwell. So was a medal medical ward. Um been uh G tube has been fitted so that that the person can be feed um with adequate nutrition three hours later, presenting with fatigue, weakness, confusion, and then for unconscious, what's the most likely diagnosis then usually will go for re feeding. So syndrome or they may ask you what's the most appropriate blood test to be taken, then it will be using yeast or including calcium and phosphate because phosphate and calcium can be quite um which yeah, bone profile, um blood tests because they are quite specific for Re feeding syndrome. Uh inpatient is needed only if the BM is really, really low, less than 13, extremely rapid rate lost more than a kilo per week, serious physical complications or high suicide or risk. Um We try not to admit these patient's uh ba because obviously they are often quite young uh admission in camps. So Children, adolescent psychiatry can be quite disruptive in their home environment, school environment. So as much as we can, we try not to. So that's why we put do it only in quite extreme circumstances as you can see. So I think that's eating disorder done as well. I'm so sorry that if I'm rushing everything but trying to point out the Saline points without keeping you here for another two hours tonight. Um, if there's a question, please start rolling them in. Um, I have some tips for psychiatry, risk assessment, risk assessment, risk assessment. So that's the thing that is likely and driving test. You just really need to point it out to your examiners. Like, have you ever thought of harming yourself? Have you ever done something to harm yourself? Have you thought of harming other people? Like, almost just make it very obvious. Uh I talk very fast. I am when I'm stressed and when I'm anxious, I talk even faster. So I always tell myself, don't rush, really slow down, let the person talk again. You want to have them on your side, so you don't want to rush them. You don't want them to feel like that you are not listening to them. You're just trying to get your question across um collateral history. Very, very, very important. Always put that as part of your plan. Uh Whenever F one I was working a knee, that's this like middle aged woman coming in who has like a lot of bruises on his, on her body and told me a really sob story about how she'd been sagged and she had a fight with her partner and some colleagues and she's just really low and down really unhappy. She's just want to bandage and she want to go home. I brought that story completely entirely and I was like, oh poor thing. And then later on when I go outside, one of my any colleague and senior is like, oh yeah, that that person is a frequent flyer. She comes into any other time she's an alcoholic. And I realized the presentation I saw is actually Cost off syndrome. So they go collateral history sometimes very, very, very important, not just an exam but also in clinical practice. Um So let my story remind you of that. If I can uh really demonstrate you active listening, I think I've talked about that already. Always say you escalate and ask for senior support. Remember you've been tested to be an F one, we rarely expand f one to manage the case on your own entirely or we always expect you to ask question. We always expect you to ask for help. So always put that into your plan as well. Uh That is part of you being safe. So please make sure you do that. You wouldn't be seen as incompetent. You want to be seen as inadequate in any way. It actually shows that you are aware of your own weak strength as well as potential weaknesses, even if you can answer everything perfectly. We still want you to say that okay. So make sure you do that. Uh Don't forget to offer leaflet whenever possible. It's a good thing in psychiatry also actually in other specialty as well. Um Like enough Singhania social specialty, you are expected to offer leaflets and information, written information for patient to go home with. Okay. So I'm so so sorry that I talked at you nonstop about an hour, 40 minutes. Any questions? Okay. Some reference here, I'll stop sharing so you can see me a little bit better. I'm happy to hang around um or I didn't put my email, but if you want to or if anyone asks, you can always share my email. I'm very happy to be contacted. If there's any clarification that anyone needs or want to ask me anything. No. Perfect. Thank you very much for that, that lecture, Stanford. I thought it was uh it was really good and the the tubes especially for places at the end. I think it's always nice to hear. I think that's something the students are always looking for because passed the exams is always that practical aspect as well. But if not, I've, I've put the feedback link in the chat. If everyone could uh take some time and fill that out, I'd really appreciate it uh for Stanford. Um and also I will share the QR code. Um If anyone has any burning questions, please whack them in the chat now or you can't confident uh turn your, turn your mic on and ask. But if not, I can share uh standards email after this as well. If you don't really like. Yeah, there's the feedback link, just take a couple moments to scan that if you can. So, oh be Oma asked you, I recommend using I C D 10 or 11 for exam. So, first of all, well done that you're aware that the I C D 11 that came into effect since this year. Um I will recommend go with I see 10 for now just because um most of the time at the moment in the clinical practice, we're still using I C D 10. A lot of the diagnosis, a lot of the treatment regime is still based on that. We are moving towards I T I C D 11, but not there yet. So I think for this year, at least I will stick with I C D 10 and to be like at your level, if you make the diagnosis according I C D 10 and doesn't quite fit into I C D 11, I don't think a mark will be deducted from you because again, uh one level, no offense to anyone that we wouldn't expect you to make the diagnosis fully by yourself. So just being aware of diagnostic criteria already gets to the point just to echo, that actually will be funny enough. I'm on site right now and a lot of people been asking that question and Alex, the uh the coordinator for the teacher, the other sites said that because our exams are written before she said, just go with I C D 10 this year. Just kind of, I'm still using I C D 10 at the moment. So that shows you the psychiatrist doctors. Are you still using that? For example, definitely signify CD 10 because the people who are examining you are most likely still using I C T 10. Thank you, Carl. Thank you for agreeing. No, it's fine. Well, if no one has any more questions, thank you very much for attending this evening. I hope it was useful and again, thank you very much Danford for giving it the time to teach us today. We really, really appreciate it. Thank very much, everyone. Have a lovely evening. Take care. Thank you. Yes, you can have the slide Raymond. Yes, I'll have the other side after this now, right? Take your time. Bye.