Computer generated transcript

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

Okay, so I got a couple of people here. That's great. Um, nice to have you with me. We're going to talk about psychosis now before I get going. Guys, were any of you at my last session that I gave where I talked about the symptoms of psychotic illnesses? Yes. Or I know they will do. Are you Are you with me? We have one. No, in the chat. Uh, all right. Don't be afraid to speak out, guys. There's only a couple of us. So if anything, this is more like a tutorial, which is lucky for us, a bit more intimate. So do feel free to pop your cameras on. I feel a little bit less odd talking to a black screen. You don't have to, but it might make it a more fun session. If we do that now, I'm going to share with you guys. I'm going to share with you a workbook in the chat bar. Uh, and this is one that you can fill in as you if you'd like to, uh, you don't have to. I will pop it up on the screen. Thank you as a nice to see someone's face So there is a workbook up there, but I'll pop it up on the screen so we can see it together. Oh, could you make me Austin? Could you make me a co host, please? So that I can share my screen while we're doing that? Guys, you can open this up and we're gonna go to page the page, Which says, what psychotic illnesses my patient's suffering from is about halfway down. Now, the first ones you can see and have a look through you can feel them in in your own time. Those are the ones that I did last time. Here we go. Screen is getting shared now. Great. And someone else has popped there. Did you go on? That's really good. Thank you very much. Okay, so I'm going to share my screen. I'm gonna show you this. Hopefully, this is up. Which can you see it on your screen? Guys? What psychotic illnesses my patient suffering from? Uh, I can see your screen. Yeah, but is it the one writing on it or it's just your Windows desktop? That's no good. It shared the wrong screen. Don't worry, guys. We will. I'll get up there Here we go. All right, so this should be the right screen for it now, OK, so we're gonna ask, what is my psychotic illness? Uh, is my patient suffering from so before we do that it is in the handbook, which I just sent to you as add. You got a question? You got a thumbs up? Not a question. That's good. All right. So let me ask you, what psychotic illnesses do we know? So patient's with psychosis? What conditions could they have? Societal behaviors or societal thoughts. Okay, so that might be a That might be a presentation that they could have. Definitely. That might be part of what's going on with them. I'm thinking about what diagnosis might that they end up with. Squints opinion, schizophrenia? That's the big one, isn't it? So the good news is, most of our patient to get psychotic for the first time won't turned up with schizophrenia. Okay, good. What other ones do we know of any other ones? It's an effective disorder. Excellence gets an effective disorder. Yep. Absolutely. That's one. Any other ones that we know where conditions where patient's can become psychotic. Okay, Sorry. I didn't quite catch that one brief psychotic disorder? Yes, so brief psychotic illnesses. So there's a couple of different names of those. So the way we do it is we start off with a patient presenting with a psychotic illness for the first time. So first ever time they get sick, we always consider organic. There's a little table with that. That's relatively rare, though. And then once we've excluded that we we like the term in the UK first episode Psychosis. Now in some countries, I will call it first episode schizophrenia. I don't particularly like that because that indicates that the it's going to grow into a schizophrenic illness. But as you'll see, lots of patient's won't ever have another psychotic episode. And we used to think that if you had an episode of psychosis, you had schizophrenia and that was it. A chronic, progressive, lifelong illness. But that isn't the case. If you get in and treat early and effectively, then patient's don't end up with long term conditions. Some do, but not all of them. But if those patients' do have another episode, then we need to think about where they might fit. So you break that down into noneffective and affective components. So effective Meaning mood? Yeah, so with a mood component and noneffective, meaning there is no mood component. So if there's no mood component, we've got schizophrenia, which we've talked about. Um, so that's chronic. So long term illness where you either have ongoing psychotic symptoms the whole time or you relapse and remit. You get those positives and negatives, symptoms and cognitive symptoms, or you could have persistent, delusional disorder. Now that is a long term, a chronic illness where there are delusions. But you don't have things like hallucinations or Pacific D phenomena or thought interference. It's just delusions. And you, occasionally people who get very entrenched, delusional beliefs about local government and things like that can fit into that. Then you got the ones that are affective components, so mood components in there so you can get psychotic as part of bipolar effective disorder. So that's where people will come manic, so mood is elevated. Disinhibited don't need to sleep very much, and then they can get psychotic symptoms when they're manic, uh, and the different and and this is, and so with bipolar disorder, they get manic and they get psychotic at the same time. How does that differentiate two schizoaffective disorder? Well, schizoaffective disorder is a bit like a combination of schizophrenia and bipolar disorder. So you have that baseline level of schizophrenia, schizophrenic type symptoms, psychotic symptoms, and then you'll have periods where your mood will go up or we'll go down with bipolar. You make a full recovery in between. Now, if you're scratching your head and thinking, hang on a minute. I'm not sure I really understand this. Don't worry, because we're gonna go through some examples so and hopefully wrap your head around it. So let's go with, uh, this chap First we've got Josh. This is April of 2018. He is 19 years old. He's got no history of mental health problems and he's got increasingly preoccupied by a pedophile conspiracy. He thinks his parents involved and has been looking himself in his room and posting on social media that they're abusing him and have been filming him by bugging him with his electronic devices. He stopped eating and watching himself. He's detained in hospital, where he remains paranoid and suspicious, but his mood is stable so we can see Josh here. This is his his mood. He's got psychotic symptoms coming in here. What do we think the diagnosis of this person of Josh is at this stage? Um, any borderline? Uh, so, uh, borderline. That's that would stand for borderline personality disorder. And that's or emotionally unstable personality disorder, Um, and doesn't tend to be accompanied by psychotic beliefs with it. So if we were to go back to our list that we've got here schizophrenia so we've got the first episode psychosis and then it breaks down. And then if they as they progress my schizophrenia, persistent, delusional disorder, bipolar or schizoaffective, where do we think Josh sits? You got a choice of five guys, I'd say between the first two because there's no mood component. Great. So you picked up that there's no mood component here and that the patient's got psychotic symptoms. Now, this is his first ever time that he's presented with this. So I would call this a first episode of psychosis because I don't know, at this stage, if Josh is going to go on and have a long term condition or whether he's going to have this episode recover and that's it, he never has another psychotic episode, so I used the term first episode psychosis for him. Now, you could call this a brief polymorphic schizophrene, uh, psychotic disorder. You could call it a. There's a range of different things you could call it, but first episode psychosis. A well recognized term that says this is the very start of this person's illness. They may make a full recovery. We don't know where it's going yet. So what are you going to do to treat Josh? What do you think I got? Jeb Ali. Elena. What do you reckon, Guys? Any ideas? Think since it's the first episode so we might not medicate, we might just, uh, uh, vocational Vocational Therapeutics so we could do observation, couldn't we? That's actually not a bad thought. We could just say this is their first ever episode. Let's not medicate them. Let's see where it goes. Maybe it will settle down by itself, and that sometimes does happen. So that's not a bad idea. And you thought, Well, maybe there's some other therapies we could use as well. We could use psychological therapies. Social interventions. Yeah, you definitely. You could if we were to use, uh, medications. What medications do we use to treat first episode of psychosis? This isn't a trick question. I don't need the names of the medication the class would do. Uh, antipsychotic a lithium. So antipsychotics. Louise, you were saying something about lithium. Now, lithium is a mood stabilizer. So if they had an affective illness, then we might well, consider that, um, Louise, what are you suggesting? Um, second generation antipsychotics. So L'anza, pine quetiapine. Yeah. Good. And the second half that we're going to do, we're going to look at the different options that are out there and the side effects of those medications. Good. Okay, let's move on a bit. Now it's October 2018. A couple of months later, John Josh has made a good, functional recovery. During his admission, he started low dose antipsychotic medication and he was discharged after three weeks. He struggled with low mood for a short while, but this got better without any new medication being started. And after the summer, he went to start university. He stopped taking his anti psychotic medication, as he was worried about his friends would think if they saw the tablets, his mental health deteriorated. He withdrew from his friends, and he stopped attending lectures. He was heard talking to himself in his bedroom. He refused to speak to his lead practitioner. So his nurse in the community, as he felt they had been removing thoughts from his head. They thought withdrawal, uh, to stop him from exposing a pedophilia conspiracy. He was detained in hospital, where his mood upon a mission was noted to be euthymic but with a flat affect. Okay, what do we think his diagnosis is? Uh, this could be plus persistent delusion. So a good thought, because we've got this pedophilia conspiracy, which is consistent, has followed through. Now the reason why it's not Can anyone say why it's not a persistent, delusional disorder because of the mood has not debated too so much The mood. That's it's not so much the mood here, but there's some other stuff that's going on. He's well, he's got other symptoms so persistent, delusional disorder. It does what it says on the tin. It's delusions only, but this guy's actually got thought withdrawal, hasn't he? So he's got and he's talking to himself, so he's probably got auditory hallucinations as well, so that means that this guy is now progressed into a different category because we've got more than one episode. So this is no longer a first episode of psychosis, and he has got depressed here. But the Depression has come right after he's been in. He's had a psychotic episode, which isn't uncommon. And when he was depressed, he didn't have psychotic symptoms. So we don't. So this probably isn't schizoaffective disorder at this stage. This is probably schizophrenia because we've got a recurrent psychotic symptoms that are occurring at times where his mood is in. The North hasn't crossed into depressed or manic. You can see there. Okay, so my treatment is largely the same. Put him on some antipsychotics at this stage. All right, let's look at this one. We move on. It's January 2022 since he was like, Hello, guys, nice to see you as you join us. You'll pick it up. We're talking about the different diagnosis you can get in psychotic illnesses. Do you feel free to turn the camera because it's not a small group? A bit like a tutorial. Um, since his last admission, Josh has finished his degree and he's been working full time. His working life has been stressful, and he has completed his increased his alcohol intake, have been arguing with his girlfriend in their rented flat. Three weeks ago, she ended the relationship and he's had to move out, and he's sleeping on a friend's sofa. Since then, he's hardly slept at all. He's got himself into 1000 lbs worth of debt, buying expensive equipment, which he said he's going to use to rid the world of pedophiles, has has been given special powers by God to achieve this mission, and he has a mental health active in the UK That's the way in which we admit people into hospital. If we need to, um, do it using a piece of law. So against their will, Uh, and he's quite irritable with the doctors. They know this mood was elated, and they find it extremely difficult to interrupt his speech, which jumps from one topic to the next in rapid succession. So we're changing topic a lot. So what's happened now? What do we think this diagnosis is now? We've gone from first episode psychosis. Then we thought we think this is schizophrenia. Now we're on to assistant sorry, persistent delusion. Know once again this guy has got other stuff going on. It's not just a delusion. There's other stuff happening at the same time. If we go back up the way, I'll take us back up. So we're breaking it down. So have we got a mood component now? Yes, we do. He's got his. Mood is elevated, isn't it? He's got irritable. Um, now is it bipolar, effective disorder? So when it's bipolar, um, you can get psychotic, but you're only psychotic when your mood is high or low. Can we say that's the case for Josh? Yes, well, we can in this in his last one. But he's had two episodes or his mood has been normal and he's been psychotic in those times, so we can't say that. So has he got a chronic illness in psychosis where the psychotic symptoms occur when your mood is normal euthymic as well as when you're manic or depressed? Yes, I think we can, because we've got psychotic symptoms here. When he's his mood is euthymic again here in his euthymic. But then when up here, he suddenly becomes manic and and these psychotic symptoms happen at the same time. Now you're thinking, Hang on a minute, Doctor Fallon, you didn't get the diagnosis right when he was first admitted to hospital. How did you make that mistake? Well, that's not. That's actually just a normal part of our clinical practice in lots of health conditions. You start off thinking it's one thing, and as information comes along, you make a new diagnosis. And I've seen that a lot when I worked in physical general medicine. But it happens in psychiatry a lot as well as cases progress. As you learn more about people, that diagnosis evolves and it changes. And that's not a bad thing. That's how things work within medicine. So what do we do that's a bit different when someone has got a schizo affective disorder. So a long term psychotic illness with a mood component so they become manic or depressed? What we do in terms of management, what might you add in? Maybe medication and therapy? Yeah, therapy is always a good idea. Uh, but what medication should we use for this chap? Should we add in? Got a couple of new people shout it out? You can't get it wrong here. mhm treatments for bipolar might continue with the antipsychotic. You definitely weren't. Yeah, that's good. So we'll keep on an antipsychotic. Anything that you'd add in for someone who's mood is a bit all over the place. And D h d uh, so a mood stabilizer is probably Yeah, he's manic. So probably so the about parade or lithium. So just as a little reminder of what we were talking about bipolar, effective disorder here, you you get mood changes. You can have bipolar type one without ever getting psychotic. That's perfectly, uh, normal. But if you are going to get psychotic, then the psychosis only happens at times when you are manic or depressed. Yeah, most often, when you manic really type two bipolar, you'll see no psychosis. You can't be psychotic in type two bipolar, and you're you're less, uh, severe. Uh, there, Okay, and then there's a little bit in the rest of that sheet that I sent over to you. All right, so that's good. Well, let's pause. They're having had a think about that. We're going to just put up a presentation about antipsychotics, and this is gonna jog your memory if you know, lots about them. And if you don't, it's going to teach a bit about the, uh, about the various so defects. And I'll even give you a workbook for this if you've been interest in having a workbook. Okay, If you want to fill in the work because we go, you're very welcome to that's gone in the chat bar. Just so you know, I'm not able to monitor the chat bar at the same time. So if you wanna you've got an answer. Just shout it out and, uh, feel free to get stuff wrong. Here is the best place to get it wrong. Uh, okay. Give us a wee sec for this to open up. So, have you guys covered antipsychotics yet? Do any of you know anything about psychotics? I'm going to stop screens, Garrett sharing whilst I get that thing up and running. Yes, They Okay, uh, screen will be shared in a minute. Do you need to know about psychotics if you're not going to be a psychiatrist? Yes. Why? Mostly we wouldn't need to pursue If we could probably diagnose properly. Then we would prescribe it, or else we would recommend a psychiatrist. Okay, so It's good to know whatever field you're working, because you might, uh, need to, uh you might need to prescribe it one day. Absolutely. Um, it's also good to know about all of your medications. Why might we prescribe antipsychotics outside of psychiatry? What kind of things might we use them for? Can you see my screen guys? Which screening is in the wrong one? Oh, see the presentation? You can see the presentation. Yes. Okay. It's moving forward. Is it? Yeah. You see the one with the list of all of the names on it? Uh, right now, we just see the title page, like, wrong screen yet again. Okay, here we go. I think I got you up and running now. Yeah, that's it. It came up and it disappeared. All right, So the point I'm making is what I want for, uh, you guys is to is to know about it because you might need to use antipsychotics with things like rapid, tranquil ization, for example, that's a really important thing to know about. Um and your patient's going to come in on antipsychotics. Uh, is the reality. So you need you. You really do need to know about it, right? Here we go. Share the screen. Okay. I think I've got it up and running. Looks right. Okay. So these are the names of some of our antipsychotics. Just a reminder of them for you. They come in two categories. Typical and atypical. The typical is being Are older ones are atypicals being the newer ones. Now I put the typical a couple of them up chlorpromazine, because even though it's not used very much nowadays, I don't know. In the UK, they really like putting it in exam questions. I do not know why. So I put that in and haloperidol, which is used a fair bit. And he's used a lot in rapid, tranquil ization. Um, so you might well come across haliperodol. I don't know if any of you have seen that on any of your attachment's that you've had over the years, but that one's seen quite a bit in our A To because I knew once you've got things like a missile pride, Arabic result lurasidone could type in lands a pin and risperidone. They also come as long acting injectables. And that means they can be They can last anywhere from 1 to 4 weeks, and they typically are injected in the upper arm or into the buttocks. Uh, so very effective for some patient's because they last a long time. You only have to give them in most cases once a month, which is really good. Uh, so good. If people don't take their tablets, you know that they've had their medication. You can tell that that they've had it, and it's convenient. So people do sometimes like that side of it. And in the atypicals Arab result, lands being Pala paradigm, uh, are the main ones. Olanzapine is not used very much for some monitoring the reason so aripiprazole paliperidone being the main ones. And paliperidone is actually, uh, what I think respiratory turns into paliperidone needed bloodstream. So they're saying and then put the typical as you've got flu pen pixel and zuko pen pixel as well as haliperodol. Then there's clozapine, which is the treatment resistant. Now all antipsychotics are created equal. They all work as effectively as each other. So our decision as to what to choose for our patient is based primarily on side effects and tailoring it to the patient in terms of the side effects that they find tolerable. The exception being closet Fine. Because closet pine is, um Clozapine is for treatment resistant and doesn't have evidence. It's a little bit better now if people are asking questions in the chat, can ask you to shout them out just because I can't keep an eye on it. Let's go around this and see if we can pick up the side effect of our antipsychotic medications. These are the most common ones. And as we go through, we'll talk about them in a little bit more detail. So number one top right in that red box. What is this? Maybe a headache. Uh, you're in the right region. Any other ideas? Some can cause headaches. How is she? Uh, no, they're quite actually antipsychotics. Often used as antiemetics. Actually. Sorry I didn't catch that. I'm sorry. I didn't quite catch that. It's okay. You can say it again. I'm sure you got it right. All right. Well, this was sedation. So all most of the antipsychotics are sedating, accepting aripiprazole, which tends not to be, Um and that can be really challenging the most sedating ones. Being a lanza pine probably can type in and closet pine. Very sedating So people can complain about those. But that can be useful if you've got people who are a manic, for example, or you haven't slept for a long time. All right, let's go down to number two. What do we think this one is? Uh, skin rash? Uh, no, it's not that gynecomastia. Yes, that's right. Quite small, Depending what screen you're looking at. It could be hard to see, but this is gynecomastia. And why do we get gynecomastia with antipsychotic treatment? Um, uh, most of them for instances, Um, the block D two receptors and which, actually, you know, the two is an antagonist of, uh, full acting. So if the two is in in impaired, if the Axion is actually, um innovated, then pull acting will walk by by increasing. Uh, yeah. So in the pituitary, dopamine inhibits productive release. So if we block dopamine, the prolactin release shoots up, prolactin goes up. Gynecomastia. What else can you get with gynecomastia? Um, decreased libido. We're going to come onto that, so you're not wrong, But I'm thinking about associated with that kind of come. Astor, you can get galactorrhea say milk leakage. And you do have to ask patient's about that because I've had patient's who've been, you know, they've only, you know, I remember one a teenage girl, and my mom said, I you know, Doctor, I've noticed when I'm washing her bras, I see that there's milk in a bra and I had her on respiratory, which is quite bad for putting your prolactin up. And the patient hadn't mentioned it to me. And it's, you know, you think that they would say that. But no, it wasn't until then. And so we switched on to a different medication and it went away. Good, right? Number three. What's that one Queezing heart rate. Uh, so I've heard two things. So I think, as I do said, heart rate, you can have your heart rate can change so you can get tachycardia with with claws up in Someone else said something else. Hypertension, I think. Was that right? Is that what you said? No, I said perhaps. Arrhythmia. Arrhythmia? Uh, no. So So we'll come onto a changes to conduction. This is hypertension. So long term hypertension, some of them can cause hypertension in the short term. But long term hypertension you can get right. Number four. What's this one? So why is there potential in due to anti psychotics? Uh, so it's long term changes probably related to the vascular system. We'll come and talk about it. We'll put some things together and explain why that happens in a moment. Number four. Yeah. Abnormal menstrual. Yes, you can see disturbance to the menstrual cycle and amenorrhea. And again, this one relates to the raised prolactin. So hormonal changes secondary to the antipsychotics. And then number five, someone already mentioned, which is a change to libido. And that can happen for a multitude of different reasons. But prolactin can be a factor. And that's for men. And for women. It's not just erectile dysfunction, although you can get that. It's around, Uh, you know, changing desire as well. Good. Okay, Number six. What have I got here? Osteomalacia or osteoporosis? Well, so osteopor in penia and osteoporosis can happen as your prolactin is elevated in the long term, you get the menstrual disruption so women can end up with a decreased bone density. So you do need to think about what medication you're giving. Yeah, and there's a risk of fracture associated with it. So you need to think about the patient that you're picking your medication for, isn't it? Is my medication. And I if I put someone on one like respiratory Anami, Soul Bride How a parador that really put your prolactin up? Who am I giving that medication to Do? I want them to this to be the risk? Or will I pick a different medication that doesn't affect prolactin like Arabic result? Okay, Number seven, what have I got for number seven? The terror skills, Yes. So increased cholesterol, which leads to atherosclerosis. And this can be a component of a couple of different things. Um, and can affect things like erectile function as well. Right. What's number eight increase in weight. Yeah, well, this is a specific increase in weight, because this is central obesity. Okay, so you do put on weight with antipsychotics, but it tends to be central, and that's your highest risk. Bet. All right, guys. Well, what's number nine? Do we think I have a question regarding central obesity? I've seen many people who have might have the anxiety disorder or when they go on the psychotic, they do gain weight. But sometimes it's considered healthy compared to other other voices gaining which sometimes considered healthy. Is it true or is it OK? So if you've got a patient who is very underweight, they're very depressed. For example, they haven't been eating or even someone who is very psychotic. It hasn't been eating anorexia, okay, not anorexia. So anorexia is a different condition in which people have a morbid fear of badness and deliberately restrict their intake. When people are depressed or psychotic, then they stop eating for different reasons. Yeah, so it's not that they've got anorexia nervosa is that they stop eating. So if you if people stop that, then it could be Then people will say it can be It can be helpful. But of course it can go the other way, can't it? If you lose lots of weight, then put on lots of weight centrally, that can be a negative, so people can struggle with that afterwards. All right, let's have a think, guys, What do we reckon for? Number eight number? It is central obesity number nine. Sorry. Who's who I got here? Guys, he's sorry. Sorry. It was sorry. I've lost my my lead. So is it is it to where? I can't see my attendees, is it Taiwo? Tiro, do you Did you say something? Um, it looks like pancreas, but perhaps from the tightest it is. Pancreas is the pancreas. So let's follow that that line of thinking. Then where are you going with that? The pancreas. What's the pancreas function? Yeah, it is. Yeah. So insulin resistance can occur, so which can lead to type two diabetes and even insulin dependent diabetes if you leave it for long enough. So absolutely. So that's a really important one to think about. And the ones that are particularly bad for that. Going to be a Lanza pine, Uh, type in in particular. Okay, which is also the same. So lands been bad for weight gain? Clozapine. Bad weight gain could type it bad for weight gain in particular. All of them could cause it. But those are the big ones. Right? Number 10. Um, does anyone know the specific condition heart conduction abnormality that can happen here. Hey, Arrhythmia. Yeah. So that's Yeah. So arrhythmia is an abnormality of the heart conduction. What arrhythmia? Might there be so sad to par? Yeah, absolutely. That's the one so and that can lead to sudden death. So this is why we care about this one. It's important. So So we do. And so that's the end result. But it's Q t prolongation that antipsychotics can cause. And let's put it out there that, like loads of medications called Q t prolongation loads of them but with antipsychotics. So we do an E C G before we start treatment and an e c G after treatment. Because if the Q t is prolonged, there's an association with developing sort task to side the point. Right. And our last one is number 11. Yeah. Hyper hyper celebration. Yeah, hyper salivation and cause a pin is probably the worst on balance for that, Although it gets complicated by its mechanism of action, you wouldn't expect it to cause hyper salivation. But it does. Yeah. Please, I have a question. Why do they cause, um um increased lipids, Atilla sclerosis And what mechanism? Oh, well, there's a variety of proposed mechanisms. Uh, you know, and not all of it is absolutely certain as to why it happens. Why does it cause increased weight gain? Well, the the predominant theory relates to the effect that it has on circulating glucose levels, actually, and so there's more glucose circulating, which then ends up getting stored at as fat uh, and it. And it seems likely that there's something that factors in with the lipids along the similar lines. I don't know the ins and outs of the science behind it, but you do see it. It's pretty dramatic when you do the tests. Um, the blood tests as you watch people get higher and higher lipids as they stay longer and longer on their medications, particularly things like a land therapy. So I've got these ones which you starred, and what do we know? If we look at these, we've got hypertension. Insulin resistant, central obesity, raised lipids. What is that collection termed? What do we call that in just in general, medicine related or metabolic? It's a metabolic syndrome. You need to know about that in loads of different fields of medicine. So learning about it in psychiatry it's just a bonus because you'll know about it for lots of other stuff as well. And what do you reckon? Guys, who I got here, Elena Allah Jeb, You guys shout it out. What do you reckon? More likely with typical or atypical antipsychotics. Is it a typical? It is a typical Yeah, Absolutely. Now, that doesn't mean that that can't happen with the typical. It just means it's more common with the typical with the atypical Sorry. Now ones which are more associated with typical antipsychotics. All right, now, if you haven't had If you haven't had your chance to shout out an answer, now is your chance. Just take ab ago because you you know, it doesn't matter if you get it wrong. What do we think? Number one is of our guys who haven't shouted out? What do you reckon? Bradykinins year? Good. You're on the right lines. You're on the right. Lansus parkinsonism. Yeah. So there is a triad in parkinsonism. So again, with the guys who haven't had a chance to shout out, would you reckon we've heard the bradykinesia is part of it. So that slowness in initiating movement, what are the other components of parkinsonism? Zor Parkinson's rigidity. Yeah, you're smashing it. Let someone else ever go because you're doing so well on this. I bet you're going to get the third one as well. I would like someone else to have a go and get the third one. Someone who hasn't had a go yet. Shout it out, Alina. Jeb Louise, you better go a bit. But you know you can have another go if you want. Maybe tremors. Yes, tremor is excellent. And do you know what type of tremor you get with Parkinson's is a specific type. Pinpoint tremors, uh, close. It's a pill rolling tremor, so it's going to look like that. So we've got bradykinesia tremor and rigidity. And when you feel people, you do this. You know, when you move their wrist around, you get almost like a a clock wheel feeling. So it goes. Clicking almost drowned as it moves around. So if you see people are on antipsychotics, typical old style antipsychotics do ask if you can do a peripheral nervous system examination. It's a good place to feel that, and we can understand why parkinsonism happens, can't we? Because, you know this is about blocking dopamine and Parkinson's happens because of degeneration of the substantia nigra, the breakdown and the reduction in dopamine there. So we're just recreating that in that pathway, aren't we good. Now Number two is a bit of a out of left field. One. I sometimes get people getting it. Would you reckon this one is guys a politic? Shizu. So I've heard a couple of things. It's not epilepsy, and I've heard a It's kind of easier. You're on the right. You're close. Sounds similar. Well, this one is a cath easa, which is a feeling of restlessness. And this can be very distressing to people. Often it can be, you know, they can look like they're pacing around. They can, or it can feel it internally. Just feel like they need to keep moving. Um, and sometimes you can get tricked a bit with patient's with these side effects. Because I remember one patient when I worked on the psychiatric intensive care unit as a very junior doctor. And he would honestly, he'd be sitting there like this, and he just looked like he was going to explode, and then he'd jump up. And then he started pacing around the ward nonstop and you know, you go Oh, wow. This guy needs more medication, so bump up is haloperidol. But actually, when I look back now, this guy must have been very, very aka this sick, very restless. And so he's really agitated because of that. And he doesn't need more medication. He needs to switch to a medication that's less likely to cause that side effect. Similarly, with parkinsonism that can manifest as hypomimia. So a reduced facial expression. I remember a young man about 22 he looked like nothing. I mean, his face wasn't really moving. You tell a joke. Nothing at all. I mean, my jokes are bad, but my consultant at the time told great jokes and he just wouldn't really respond to them. And you think Wow, really blunted affect. He's very affected here, isn't he? But actually she was able to see that this was someone who was on risperidone and was experiencing parkinsonism. And she switched him on to parapet result and he came back to life. And suddenly all that facial expression was back. And it was the medication that was causing him to look like that, not the illness. I've diverted us for a minute. Number three, what have we got here? We've got a chap here, and actually this is the guy's neck. Actually, that's in this position. It's the neck were interested in here. Any thoughts? Shout it out if you were thought. All right, this is a dystonia. And this just toast. Tonio, for this person is in this bit here. They have a fixed flexion deformity of their neck here and with antipsychotics that can happen in any skeletal muscle, including the tongue, actually. So fixed flexion deformity. That happens with this because the tone goes up in that muscle, you have to withdraw the medication. You can use Botox if it's very severe. Okay, My last one is number four. And it's a the best version I can do of this because I really need it to move to demonstrate it. It would look like this. Anyone know what that is? Lip smacking. It is lip smacking. But do you know what the name of the the syndrome is that? That we call that? Uh huh. All right. This is Yeah. I just said label because it was lips, so I don't know whether that's right. It's not that this is a tardive dyskinesia tardive, meaning it comes on late in the treatment. So you're not going to see this in week? one. This usually will be months or years after starting treatment, and it starts with lip smacking movements or little movements of the tongue involuntary. And if you left it long enough, it would progress to Cory ick movements like you'd see in Huntington's career. Now we don't do that nowadays. Nor do we use doses that would give people that kind of response. You have to take them off the medication if they experience this, because it's only likely to get worse. So you switch them on to something else. That's your treatment. And it's probably down to super sensitivity, super sensitivity of receptors. And that's why it happens. And that's why it takes such a long time for this one to come on. And these are mostly with typical antipsychotics, but they can happen with some of the atypicals, but mostly the ones that have got a high potency for D two receptors. Say, um, respiratory in and hide a same sulp, right? All right. Now, look, here is the list of some antipsychotics, and here is the side effect profile. Tell me, what one are you going to pick if you've got to go on one of them. What are you going to choose? You can type them in the chat bar if you want. Probably Arup it. Brazil. We've got a vote for Arup It Brazil. Anyone else? Um, Ms I miss like pride. I mean, soul pride. Yeah, it was a good anti psychotic downside. It's twice daily, but it's a very good one. I like the soul pride because I know about the prolactin effects of family sold part, which is why it probably would be my first choice, but Yep. Okay, well, to me, it's obvious that you know where your best ones are. So I I wonder why. You know what have you heard of me? Aripiprazole Aripiprazole? Uh, it's old bride with these medications you're familiar with. Have you ever seen antipsychotics used in practice? And if you have which ones have you seen? Haliperodol Haliperodol cheap as chips is haloperidol. Where have you seen haloperidol used? But you mean the like in a general ward on a psychiatric ward? Um uh, you know, an end of life care where psychiatric ward in psychiatric ward, Because haloperidol is used in lots of different conditions. Um, it's good because it's cheap. Which is good, Um, and it's easy to get hold of, um, but the side effects will be quite punchy if you go to high on the dose. Um, and what I always say to people, it does rather depend on what the funding situation is like. You know where you're working. But I always say, If you're going to prescribe a medication for a patient that you wouldn't take yourself, you better have a good reason for it. If I look at this list, I think there's no way I'm going to take a Lanza Pine. Look at all of that sedation, weight gain, lipid disturbance, anticholinergic effects. I don't fancy that, so I don't generally prescribe it for my patient's unless I've got a very good reason for it. But I see a lot of patient's started on a lands up in. There's a first line treatment, why it's not any better than any of the other anti psychotics, and it's got side effects that I don't think that the doctor's prescribing it would want for themselves. So if you don't want the side effects for yourself, why you're going to choose it for your patience? Just have a think about your prescribing choices. All right, Quick. Yep. Okay. I guess you're about to do that. I just wanted to have, uh, the, uh, pre, uh, the the I think the best choice from the other side like this Is every proposal out of the way? How does it work? It's a It's a partial agonist. It don't mean receptors and has other actions on the five ht to a system. The reason why it has fewer side effects or a better side effect profile is because it's a partial agonist. So it's It sits in the receptor and activates it, but not as potently as D to does. So it blocks it. So you're circulating. Dopamine can't activate the receptor, but it's still having some effect on it. So you don't get a lot of the side effects that you would get otherwise because you're reducing the overall effect down but not cutting the effect of the of the dopamine off. Then it's got all those other things that come alongside atypical antipsychotic actions, which is that the action on the serotonin system, the five ht to a system, and that's probably why it's it's got a better side effect profile. So it activates both. It increases dopamine and serotonin. No, it doesn't. So it reduces the overall effect of dopamine, but it doesn't completely antagonize it. Right. So risperidone sits in a in a D two receptor and blocks it right. Haloperidol sits in the receptor and blocks it. Dopamine can't have any effect in it. Right. So you get lots of extra pyramidal side effects. Those movement problems. Yeah, Uh, aripiprazole is a partial agonist, so it partially activates the receptor. So you get some activity, but not the full amount of activity that you would get if you didn't have it sitting in the receptor. And that's why you don't get the same kind of side effects that are with it. Yeah. Does that make sense? You said it's seratonin as well. No, no, no. It has an Axion on the serotonin system. But that's, uh, that's quite it's going to get quite complicated to talk you through that and beyond. What? I'm going to talk. Mine's a clinically orientated one, not the underlying psychopharmacology behind it, which I've got a separate session on that which, if you're desperate to here, I'll do it another time, but that's that's an hour session by itself. So there's a clinically focused one. So you you know, the important thing to remember is that it doesn't just act on dopamine pathways. It also acts on serotonin pathways. Okay, does he does. He doesn't have the same effect, like the typical world like it's effective. Yes, they always they are all as effective as each other, except for close up in. So you're picking your choice of medication on a basis of side effects? Yeah, which is why, usually for me, I look at this list and I say to my patient's, Would you like to try Aricept Resolve? If they say I don't want to be really sedated and put in lots of weight, I'll say Great olanzapine. Now clozapine is a bit different. When do we use clozapine? Anyone, then? Okay, well, Khloe's opinions for treatment resistant psychosis. What does that mean? That generally means you've had two full trials of antipsychotic medications, other ones than closet fine, and the reason why we reserve it for treatment resistant cases is that it has a side effect called a granular cytosis, which means that it can cause a breakdown of white blood cells. And that could be dangerous because, as you're you know, I think it makes sense if you your white blood cells are broken down, they can't bite off effect infections. So we need to monitor, uh, people's full blood count and check that their white blood cells are in the normal range if we're going to carry on prescribing it. And in the UK, I'm sure it's different in other places. But in the UK, we do we when they start on closet and we do a blood test once every week for 18 weeks, then once every two weeks for 18 weeks. Then we test their blood every month to make sure that their white blood cells are okay. And if they're not, they don't. They can't have the medication. That's how seriously we take it. But there are other things we need to think about the Klonopin as well. And you could bump into close up in in general medicine and general surgery. Okay, because of the side effects, it is. You've seen weight gain sedation it can cause tachycardia always does actually cause tachycardia and, of course, postural hypertension. But it also can cause constipation, and that can be very severe. And you think constipation? Oh, who? You know, it doesn't really matter a bit of constipation, but actually, this can cause a very severe uh, probably, Uh, where where you end up with a toxic megacolon and people die from it. And in the past year, someone in the trust that I work for someone has died. Um, due to that, um, So you really need to monitor people's, uh, bowel, uh, emotions as they as they're on this to make sure that they don't get constipated. And those people will need to go on some, uh, something like lacks a dome over call or send a combination of things to help with to avoid constipation. Uh, smoking is a factor because smoking affects the levels of the clozapine. It's not the nicotine. It's the other stuff that's in there. The targets in the the cigarette smoke and that causes the clozapine levels to go down. So people stop smoking very suddenly they stop smoking, Then the clozapine levels will go up and could become toxic. So you need to weigh that in a balance and tell people you need to let us know if you're going to stop smoking. Oh, and that was it with five minutes to go. Now, if you've got any questions, I'll be really happy to answer them guys anything about psychosis, psychotic illnesses or antipsychotic treatment. So I'll be happy to talk to you about that if you've got any questions. Um, just before the slideshow began, you were talking about other conditions that you would prescribe antipsychotics for. Yeah, it's okay if you could explain that a little bit more, please. Okay, so antipsychotics are poorly labeled because they treat a host of different, uh, conditions. So antipsychotics are effective in bipolar disorder. Very good mood stabilizers, both in treating manic episodes, uh, in stabilizing the mood to prevent manic episodes and to a degree, depressive episodes they used in the treatment of, um, depressive episodes as augmentation alongside antidepressants. Atypical antipsychotics in particular. Uh, and some have a license for that as well, and then you can use them for other things above license. So, you know, so out with the license that they've got for, uh, for that for a particular condition. So we'll use them to manage things like emotional intensity and emotionally unstable personality disorder. You can use it in anxiety disorders in the kind of the way that we might use things like diazepam. If people get very anxious, you can use a low dose of something like co type, which can bring the anxiety levels down with that. And then there's a range of I mean, I've seen them used in things like a d h d to augment the effect of stimulant medications. I've seen them used in chronic insomnia. Um, there's a variety of different things that you can use for Israel. Range. Amazing. Thank you. Anything. Any other questions, Guys? Yes, please. I do. I'm for anti the presents like, um, Senate, Urin, um, and norepinephrine of the vetoes. Some are used in case of, uh participating. Like I'm wondering, why was the how do they help the screen? If I understand your question, you're You're saying sometimes we'll use antidepressants in the treatment of psychotic illnesses like schizophrenia. No, no, I mean some Can we talk about and answer the president's? I'm talking about answering the president's as well, except some of them. I used for pain to relieve pain, especially neuropathic pain. I'm asking, How do they help with pain? There's a brilliant questions. So you're speaking about duloxetine, which is used to treat neuropathic pain and amitriptyline, which is used to treat, uh, neuropathic pain. How do they work? I don't know. Tricyclic antidepressants work on lots of different neurotransmitters. Duloxetine works on serotonin and norepinephrine. Ergic neuro transmitters. How does it work? I don't know. It's the answer to that. I'm afraid when you've got your Depression one or your session on pain, I suggest you ask them. I'm not my area of expertise, I'm afraid. But nice to be asked a question that I don't know the answer to any other ones out there. Yeah, yeah, yeah. Um, clopra. My thing is one of the oldest Typical. Is it still in used diplomas? Chlorpromazine isn't used very much. It's got a couple of side effects that mean that people don't tend to use it. I've seen it used once for someone who's been on it for, like, 40 years and just have been on it for a very long time. Um, that's the only time. And that was probably about 10 years ago that I I used I prescribed it um, it's not used very much in this country. Whether it's used in other countries, I don't know, but but not very often. I think Hannah parallels as cheap and doesn't come with the same side effects. So people, uh, said that there's a lovely thing that said, Let us know that you enjoyed this lecture. We don't. If you didn't enjoy it was awful. Then you don't need to say that, Um, any other questions before we wrap this one up? Really quick. Question. Um, I wanted to ask, So, um, D s m five and I c d 11 have really different definitions of psychosis and schizophrenia, and I'm aware in the UK that I CD 11 is used, but I just wondered if you have any thoughts on the diagnostic process and yeah, okay, so I stayed 11 new when we're still in the UK Clinically. Mostly, uh, you know, a bit adherent eyes d 10. I'm not sure all of us have updated. Um, And there there are variations between that and the DS. Um, uh, the clinical assessment. We tend not to be rigidly adherent to it and being really, really adherent to a diagnostic classification system. I don't think it's that helpful. When you're dealing with human beings. It might work out really well. If you can say, Well, here's some numbers that very clearly prove that this is acute kidney injury, but I don't think the mind is quite that easy to clearly define. So I think, in clinical practice, yes, we give diagnoses, but we often have moved to a formulation. If things were complicated, sometimes it's really bond or obvious, really clear. Sometimes it's not. Sometimes it evolves. So you know those systems are there to support you to ensure that people get the right management and treatment. Um, but we don't. But that's not the and you've got to learn them for your exams. But in clinical practice, your global impression and your formulation is much more valuable than just slapping a diagnosis on someone. Is that a cop out? I don't know, but I know that was really useful. Thank you so much. All right, guys. Well, that's hits four o'clock. Thank you so much for your time. Really? Appreciate all of you joining us for that. I'll come back in a new year and do some more stuff on psychosis. We'll have some, um uh, some more lecturing kind of stuff. Maybe some videos and things. Nice seeing you all. Thank you, Doctor.