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engage in the pool meeting is being recorded the's engagement balls and email us if you have any questions, please. Please. We work on a social media. We work for free. So please, Charis and only social because and recommend us to your friends if you really enjoy the teaching passion. Fantastic. So I'm just gonna get on with the teaching session now, Um, I'm not really going to do a self introduction, but how will I will be giving the 1st 1st part of the lecture? Um, yeah. Fantastic. Okay, so let's get started. If one of you guys could be in charge of the pools, that would be wonderful. We have reverted back to questions before the explanations, just just cause it would be a really good test to see if if you understand the concept, if you're able to dermatology was a bit tough. And so we kept the questions after, because it's a you know, it or you don't. But with psychiatry, hopefully this'll just test on your knowledge and your clinical application skills. Cool. So it's gonna be delivered by myself and Alan, I'll be split into two parts. Let's start off with the first question. Um, are you guys able to see the whole Yeah, right. Antacid. I think majority of you guys have got in this right. A relatively simple question to start us off. But yet the correct answer. History from parent function tests. And now the reason why this is is because let's have let's analyze the question low mood for Dick, loss of interest, loss of energy for the past month. You're thinking of depression now. Depression can be caused by a psycho psycho social causes or biologicals causes, and you want to rule out the biological causes before thinking of the psychosocial causes. And so there are many different tests that you can do. But in the set of five, options to do it prior infection test are specifically looking for hypothyroidism. But a case of hyperthyroidism also could possibly cause depression more likely anxiety than not. But the hypothyroidism is a biological cause for depression that's going to the next question now. Um, yeah, I wouldn't read out the question so that you guys can focus on it and drink on. So the second it was launched, one person just put cognitive behavior therapy without yeah, get a few more. 10 more seconds and then we'll stop the Bulls, right? So majority of you guys, 65% of the guys actually went for cognitive behavioral therapy, with the first person clicking it in about two seconds. But unfortunately, in this case, it's actually easy electroconvulsive therapy. And let's let's dissect the question of it to understand why this is the answer. So the same 21 year old male, it's the same context presents to the medical assessment unit with low mood fatigue and loss of interest. The key difference between the previous question and this question is that he's presenting for the past six months. So you need to know the duration that he's presenting. And it's a sort of a longer, longer duration. So you're thinking that he has is more of a psychosocial, uh, depression rather than a biological depression, because it's been going for long and he hasn't really presented. He's also young, so it's It's quite common in the young to experience this type of, uh, depressive episodes. I do apologize before we start. This is a psychiatrist session, and I completely forgot to say it will cover quite a few touches topics. It will cover psychiatric topics, and it will give you the main common presentations off all these different psychiatric topics. By no means to be mean to stereotype o r Make it generic. We're just giving out our sort of Uh huh. We have studied it and how we have seen it. If you do want to learn about the exact condition, please, please refer to your your The resource is online, and if you do suffer from any of these conditions, please please seek a professionals help. We are doing this as educational, too, and we do apologize in advance if it's if it's stereotyped. Or if if there's certain, uh uh, if there's certain conditions that have generic names generate science and the kind of things we we take it from, what we see and what do you read about? Yeah, so let's get back to the question. Sorry, I just had to do that disclaimer before starting the psychiatry atopic. Yeah, but going back to this question, he's had a recurrent, suicidal ideations for the past six months. Longer time, young in the young male. So you notice that he's quite rigid and he's staring blankly into space. Now these are symptoms off a phenomenon called catatonia. Catatonia is when you sort of get very rigid, as, as mentioned, the question you stab blankly. You lost all conscience, not consciousness. But you just become very, very rigid, and you don't. It has a huge impact on your on your functional abilities. Sometimes you can just drop because you just become rigid. You're not able to control your muscles. And so these are signs of catatonia. And when you noticed the sense of catatonia, the first indication is electroconvulsive therapy. And the reason why that this happens is because you don't want thie because it's severe depression and you don't want a sequel. The off the severe Depression, because secretly of the severe depression, is really suicidal suicide itself. Or it could cause brain damage on. But what this electroconvulsive therapy we throw around these terms. But it might be actually good to understand what exactly these are and why this indicated the reason why it's electroconvulsive therapy for severe depression. What electroconvulsive therapy does is it actually inserts a few strips on to your head, and it actually stands. Shock waves into the brain, inducing a mini seizures that sort of in the temp to reset the sort of thinking, the basal ganglia, the CD, the core centers of your brain itself so that these type of symptoms are not being a noticed. And so that's why you to stop these symptoms from progressing really quickly. You want to give electroconvulsive therapy. Now Many people went for CBT, which is the first line, Um, for for first, a second line for for depression in terms of conservative management and so CBD. We'll talk about this in the next few slides. But CBD would be indicated if it's not a severe, life threatening depression. DBT is more indicated towards personality disorders such as personality disorders and possibly OCD, but really useful city personally disorders. Many DBT and EMDR movement desensitization therapy is used for um PTSD. Mainly family based therapy are used for seating disorder orders, which Michael Helen will cover the later few slights. It's used for conditions of such as anorexia nervosa, where it's more of the younger population that affected rather than the older population. So depression is defined by three key symptoms. Antidonia energy and depressive mood have given definitions all they're generally acute depression or depressive for depression to be diagnosed. It needs to be for more than two weeks. And they're certain diagnostic features that you can actually used diagnostic questions that you can use, such as the hospital anxiety, depression scale, the JDS This The scale has seven questions for anxiety. Seven Questions for Depression It's not a very, uh elaborate method of diagnosing depression for elaborate methods of diagnosing depression. You need to do a mental state examination, examine, examine the person's cognitive function, and so that actually takes a lot of time. So they tried in acute setting to assess this and education health question as well as a young patient health questionnaire and, as I mentioned, clinical symptoms as far less mental state examination. So there are a few organic differentials that could come with a person with with depression, as I mentioned, hypothyroidism, parathyroidism, calcium, high calcium bones, more stones and groan sake of months. And so this. This could present us a depressive symptom acute depressive center more than chronic depressive symptom. Parkinson's disease. In your oncology, that means it's a tumor in the brain, somewhere around strokes and dementia, because both strokes and dementia could all the people's mental status now dementia is a key point. Note that when in all person 60 70 year old person and this is commonly seen in SBS, where a 60 70 year old person presents to the to the to the GP with sort of depressed depressive symptoms and things like that with other demand symptoms that could be associated dementia. We tend to go for dementia because of the Adrian. And it's not wrong because the demographic is is more likely than not to have dementia. But then we need to consider depression as a possible cause, because in older age is you get loneliness could be a really, really fact if you if your partner is unfortunately passed away. And so it's really good to screen for these type of things in the older population as well, because a day, end of the day there are also people. They also experience the same thing as younger people. There are a few substance differentials that we can we can talk about marijuana, alcohol, cortical steroids. See your CPS on a schedule mean and these are a few things that you need to rule out. It's always good to ask the question. I'm sorry to ask, has any illicit drugs that you do? And it's sort of rules out just off symptoms. Marrone has also sensitive with psychosis, so let's try to. It's really hard to put a definition on these type of conditions, but we try and we use guidelines to sort of define how we treat the conditions basically. And so I have listed that the the, uh, the the criteria of the D S m five. But you could use the I CD 10 also to, uh, put a put a pin on depression and how you gonna manage it? So these are the general symptoms that you notice with depression. Some threshold will be less than five mile depression is created and are equal to file a greater than I go to five and mild to severe. The Persian would be that this functional impairment and the key point that we discussed in the question is that the 21 year old male was experiencing catatonia and catatonia is life threatening depression on. So for that, you go straight to the CT electroconvulsive therapy, so there are a few steps of management and this is more of a conservative approach to sort of talk about things before because you don't want to start. SSRI is immediately so, therefore, main methods off conservative management, firstly, sleep hygiene and active monitoring. The's patients are These people experiencing depression tend to not really get too much sleep, and so they sleep cycles are really affected. They tend to stay awake till five AM and yet stuff. And yeah, so it's good to have a good sleep hygiene, such as not using your phone about an hour before before sleeping now, not eating an hour before sleeping, eating a bit earlier and active monitoring. Then we move on to individual individuals. Guided self self help on CBT. So this is when the individual person sort of stays at home and sort of things about the reviews material sees how they can. They can improve themselves home, help themselves out. And then this computerized CBC, which is the next step better. CBT is basically going through the CBD in a in a computer, and I know it sounds like I'm just using the using the words to define it, but what that means, the reason for the indication is basically because they feel a bit awkward or they don't want to talk to a is a psychiatrist about our psychiatrist or a psychologist about their problems, the symptoms and stuff. So they tend to do it over the computer, where they're they're guides and their their websites that they can go through the material that you can read through it. Swell and finally, structure group physical activity would be the next step. So that been courageous. These people to go mingle and have social interaction so that hopefully it improves their symptoms. All right, so in terms off, how do medically manage depression there? Certain criteria on that on for persistent and subthreshold symptoms are mild to moderate depression. You you do all the psychosocial interventions we talked about in the previous life, but also you consider accessorize. If it's getting slightly more serious from for moderate to severe depression, you give antidepressant as well as high intensity psychological intervention where it's it's not. It's not highly demanding on them, but also it's a few times a week rather than wanted to once a week. And as we talked about severe, life threatening depression that's been going on for a very long time you'd consider electrical convulsive therapy. And there are a few contraindications for this CT the contraindications for this would be increased intracranial pressure aneurysms as well as recent myocardial infarction. Okay, so let's talk about the the drugs itself that the SSRI is that we're going to give. And later in the in the presentation, we're gonna talk about the exact more of the mechanism of this SSRI as well as the contraindications and a bit of pharmacology. So the first line is such a thing for people who are over 18 and fluoxetine for people who are lesser than 18. But if you see that they've had in my cardio infarction sexually, it's actually quite protective against the myocardium and so centrally, and it's quite prescribed. Citalopram is also first line, but you obviously need to do a SED to rule out long you descend from before prescribing it. But now, now, more than not, sertraline is the one that's being used in those above 18 and, to be honest, below Indian, also sexually insulin being used. But this are we go according to guidelines. Now the second Linus SNRI, certain object and nor adrenaline reuptake inhibitors benlafaxine on duloxetine, and you had this. A second line and their line on Matassa be appropriate on appropriate as well, a straight trazodone. And these are as an arrow. Is this analysis on in a different category of drugs, 11.2 Not with appropriate is that it actually reduces seizure threshold. So it would be good to rule of people with epilepsy to make sure that they're not on any anti epileptics before prescribing on finally pregnancy. There's there's no particular safe drug that they say there is paroxitine. It's set to be all right. It increases congenital malformations in the first. It said to be a bit toxic in the day, but that's not too much evidence because you can't really test it. But in general, from from where I see it being prescribed, sertraline is the one that's prescribing pregnancy also, and obviously you do continuous monitoring. So there's no that's not really that's not really a controversial controversy. There a key 0.2. Notice that the where when you prescribe it, SSRI and the person comes back in and we got to say it's not doing anything you still need to wait for it because it takes about 4 to 6 weeks to start working on. Been stopping. Also, you need to it takes. You need to wean it off slowly because then that would be withdrawal symptoms if you take it off too fast and when you start the SSRI patients above 30 need to be monitored to weekly patients below 30. I need to be monitored Bt for suicide risks because the moment they started sorry, there have been studies that have shown that people are more suicidal. And so please think about this and please be careful before prescribing it, right? So let's talk about depression, depressive risk factors of the respect, factors and protective. And after this, we're gonna talk about how to assess a suicide risks that that's really, really high yield topping that tend to come in SPNS. So depressive respect. It's family history of mental disorders. One of the register register as recently told me that any condition to say, a past history or a family history of that but the same condition that's usually one of the main risk factors. Previous attempt of suicide, severe depression, anxiety, feeling of hopelessness, personality disorder together with depressive factors alcohol, drug misuse and mail. Other respect us as you can see family history and all this kind of the different other risk factors. And finally, protective factors are social beliefs, religious beliefs and Children, especially when they're young. Because it's a young child. They wouldn't want to leave. Three. Young child, really? And so it's It's considered a very high protective factor. That's one of the key questions you ask in a psychiatry history as well. So this is how you ask for suicide risk. There are few about seven questions. You need us if they if the person has suicidal ideations, if they think life is not worth living, do they have plans to intend on life? Have been told anyone about that? Have they made any preparations the means of suicidal act and support available? Now, if you're assessing a patient who has come in after attempting suicide one. Are there any non protective factors such as didn't take any precautions, such as locking the door lock in their their their their house, not telling anyone about about it, not making any plants and stuff these people can to be at higher risk for for attempt suicide in the in the near future. And so it's it's really key that you probably section them and bring them into a a mental health hospital so that you can, slowly a plan treatment out. This is just a slight on the possible outcomes that could have been post partum. So that's after delivery off a baby. Baby blues usually happens 3 to 7 days post delivery. It's actually quite common. The mothers are very anxious. They're full and irritable, and reassurance is the main. A method of treatment. Postnatal depression usually happens about three months after after delivery. It's similar to normal depression itself. So that's why you need to give CBT conservative management. And if it's severe surgery in a paroxitine, the's drugs don't have any too much effect on breast feeding. So it's already there breastfeeding and finally pump your psychosis. It usually happens about 2 to 3 weeks Post delivery. The symptoms usually are sort of where the mother is holding the baby and saying, Oh, it's only my child and me, everyone is against against me all you you didn't really do this or three hallucinations and stuff that we're going to talk about it in the next few slides and then say, Oh, someone wants to kill my baby, so I really want to hold it. You know, this mood swings, disorder perceptions and literally hallucinations. The key thing here is you need to admit them to mother and baby unit. And in this region where where I'm from, that is in London. So they're they're they usually send to London if they're very, very high risk on. There's a high risk of recurrence for many off these conditions, but the bureau psychosis more than anything. So that's why they need to be really, really monitored. And this recurrence doesn't have to appear just after the next delivery can happen during during a normal day to day. But you also that they have a episode of psychosis. And so this this is something that you need to you need to consider and remember. All right, um, let's move on to the next question Now. Um, I'm just I just looked at the at the chat. I think the admission is not always necessary. People can be offered home treatment. Demon put in positive risk taking. Yeah, so it's it's really, really situation dependent majority of the mothers, To be honest based on my experience, is well, I've seen a few of mothers with people psychosis. Uh, they tend to get admitted into the mother and baby unit. Um, I think it's it's a thing more based on the guidelines. But obviously, as we practice medicine is more evidence based. It's more, uh, depending on the patient itself. So you have to see what exactly the patient would would want. What are the wishes of the patient before I have a conversation with them, with them, to be honest and see what they like before. Unless there are harm to self harm to others, it's good to have this conversation right. Let's end up all that. It is a split between C, D and E, with C being the highest education and active monitoring. Now let's talk about this patient. Let's identify the symptoms that she is having, uh, and let's try to maybe not put a pinpoint diagnosis on it. But I tried to figure out what exactly is going on. So 66 year old female presents to the GP. She's feeling restless and having difficulty concentrating and difficulty controlling feelings of worry. Now this. This is really, really key phrase, difficulty controlling feel, feelings of worried because they sort of put a few words into your mind, such as anxiety worry, sort of nervousness. And so this tends to be more likely that this would more likely than not be good. We will be going down the anxiety pathway just past medical history of COPD, with the latest acute exacerbation being six years ago. She is on sale Metro Metro p um, and was recently started on Prednisolone for polymyalgia Rhuematica. So the next step off management is actually he here. Now I'll go to the reason, and as I mentioned before, it's always good to rule out biological courses before going over to psychosocial causes. Because the moment you put your pin point a psychosocial cause for a for a certain feeling for certain mood disorder or something, it is something that's going to impact them in their life. So you want to try to rule out certain things first before trying to try to go ahead, possibly diagnose and possibly give them a few medications for him. So there is a reason why I put tell Metro less less prednisolone here. So beautiful is actually one of the drugs that causes a bit of anxiety, but it's very short lived, so it's not something that last very long. But she was recently started started on prednisolone. Steroids are actually a big risk factor for, uh, anxiety and shocked um, cigarettes, especially on days. So this is a a sort of a condition because you can see that she's having restlessness, difficulty concentrating. And that's why I have included difficulty concentrating because there is an impact on the day to day living day to day functionality because she's having difficulty concentrating, so that needs to be certain steps to be taken. And so you want to try a low, appeared without steroids or slowly taper down the steroids to see her response to it. If that doesn't work, you start her back on the steroids and try something else, such as education, active monitoring, because you want to rule of the biological cause before going to the psychosocial cause. So let's have a chat about general anxiety disorder and panic disorder. General anxiety disorders defined as excessive worrying height intention as I manage an organic causes salbutamol to fill in and corticosteroids, caffeine as well. So the management would be education monitoring, low intensity first, followed by high intensity. And then after that you go for medical management, which is high dose, essentially, and second one would be duloxetine or venlafaxine, which are in our eyes now. Panic disorder. There is a strong genetic disposition. It's recurrent panic attacks. And the way Lassic Lee is a spot trade is people breathing into the bag. But that's I don't want to be too stereotypical in describing this panic so it could be someone could be experienced in the panic. Dis panic symptoms without even expressing themselves on a on the outside basis so it changes. It varies from person to person. So it's It's really, really important that you're considerate about that. And you you sort of Austin about these symptoms and and what they feel that's usually sometimes as a trigger that sometimes there's no trigger that could, it could be, could just could just be a generic to the management would be reassurance as well. It's breathing excess because you usually know noticed this increase work of breathing. The next step would be CBT as well as SSRI. Now these SSRI don't work and the psychosocial factors management don't work. Then you consider try cycling and the antidepressants dress I clicks are particularly in this case, not a metric Lee. It's imipramine or clomipramine on. They have studies that show that it's relatively useful as a second line treatment. So anxiety general anxiety disorder is excessive worrying for over six months, difficulty controlling this worrying restlessness, irritability, muscle tension and the one of the key points that the D is, um five really highlighted is that it shouldn't be attributed to any medical conditions as well. S uh, yeah, any medical conditions are caused by any medications itself. And so that's why you need to rule out the biologics before moving on to a general anxiety disorder. There's no sort of secretaries to define it as mild, moderate or severe and implemented into the treatment regime off the condition itself. But this and the general sort of things that you notice with general anxiety disorder, right? Let's move on to the next question here, but someone launched pool, you know? All right, majority of you guys went for see, with a few of you guys going for a. The right answer here is obsessive compulsive personality disorder and obsessive compulsive. So we'll talk about obsessive compulsive disorder in the next life. But the reason why it's obsessive compulsive personality disorder is because this the the general perception is that a person with this type of personality disorder is, uh, it's more of his personality, is, is, is his choices, and his choice is basically that that so that defined this sort of personality disorder rather than obsessive compulsive disorder. Obsessive compulsive disorder would be too broadly speaking, be obsessions as whether it's compulsions deck, satisfy them to a certain extent but cause more anxiety rather than anything else where it's obsessive compulsive personality disorder. The generate type of that that people say that they see is that a person spending a large amount of time in their work and trying to be a perfectionist at the work itself while losing out on a bit of relationships a bit of social interactions. So the moment this social interactions but comes into play. It's not that it couldn't be affected in a post obsessive compulsive disorder, but a personality disorder is more likely. Um, then a generic. So these are like the t t point in a question in SP that you can sort of pick up and try to find the right answer. So obsessive compulsive disorder is known. Assist the finest persistent recurring thoughts. Urges are images that lead lead to repetitively behavioral patterns. It's generally under cerebral t. They get a lot of anxiety when if they don't do it and the way I like to remember it. And this is my method of remembering, um, on my example of remembering that rather than anything else, it's not a good way for it to be portrayed. I don't I don't endorse it, but it is. My were remembering is that I don't know if you guys watch this show. Call it, obviously, in Philadelphia, where Charlene Mother that I sort of used Charlie ST name Charlie's mother actually has to switch off like owning off on three times. Otherwise, she quotes that Charlie would die on. This is obviously over exaggeration, but that's how I remember this sort of sessions and compulsions that get this sort of obsessions People. People get this sort of obsessions that make them really uncomfortable, and they have to perform a Cup task A compulsive task, uh, in order to sort of satisfied, observe that obsession but not completely removed, an element of anxiety that is causing the performance of the task So it can be very distressing for the person's emotions. And it's often recurrent rapidity of actions. As I mentioned, switching on and off like three times or four times how many of the times it is could be the general arrangement of certain things on stuff again. So it is a clinical diagnosis, and it usually is. It usually is clinically diagnosed if, uh, you see them spending more than an hour a day, and they seem to have significant distress and impairment. India Italy Function treatment, as always, is psychosocial and biological. Second, psychosocial First, the conservative management. We should be cognitive behavioral therapy, and then you go for this new term. That's exposure in response prevention. Now what exposure and response prevention is. Basically, you expose the person to eat the particular stimulus that causes them anxiety, and then you see the response. But however you offer them support during the response so that their their mind sort of associates this support being available when they're responding to their obsessions on. So this sort of association helps them out in in elevating the symptoms for the anxiety. Now, third line would be biological would be sexually. But however, if they have body dysmorphic disorder and you want to give fluoxetin because studies section that this has good outcomes. And finally, if it's very severe used SSRI, uh, and CBT together, obviously, if it gets really, really severe your increased intensity of the CBD and the SS on ramipril All right, let's move on to the next question. Yeah, yeah, that's a good one, Sheldon. Knocking on big bang theory, knocking three times or sitting in the same spot. The management off Panic disorder. First line is SSRI. Second line is tricyclic so well, no, no. Uh All right, let's that ended. The majority of your girls have gone for clang association. Now I started breakdown this question, as we always do, you examine a 33 year old male who is a known schizophrenic. So when when you you remember, it's a known schizophrenic. You remember that all the different different features of schizophrenia rights, auditory hallucination, Snyder's 44 rounds comes into mine, and this this particular question is talking about this under, uh, the the addiction that that this person uses eating wires like lightning fire. Not client association particularly, um is sort of rhyming words that are quite they're not too far spaced, that they're quite narrow space, and they're nearby each other. So it would be something like, um, off the top of my head. Um, going blank. Yeah, so? So it would be a rhyming rhyming, sort of, sort of. I have examples later on in one of the sites, but China sensations will be rhyming words in consecutive followings with the lead and or the being the separating factor. In this case, eating wires like lightning fire is not really a clonus is he just can't really drive me. Although wires and five years would be rhyming, it's this is this isn't considered a climb association. So the right answer for this is actually word salad. Uh, and this is a actually a classic example of word salad now, actually a, uh where the echo echo D as it mentions a look in it because he's out of words. Circumstantial speech is when correctly if if I remember correctly, it's it's when there's a it's based on the situation. A situation based and loose association is when there's not a coherent sort of that, then you can pinpoint that this to stop has a association of this to go to the next thing that they say a sickly. So let's move on to the next question, which is sort of looking at the treatment. Bit off. Schizophrenia. Yeah, so you're being lings sling, or could be being going and seeing or they're being linked. Anything that's that's clanging. All right, this is a This is a relatively tough question, huh? But it's I guess it's good to be right. Let's call it there. So this is actually it doesn't this mixed sort of answer to this on some plantain share, the results of the new guys can see, with majority of you going for a second being be followed by BNC the right. So first, let's break down the the question, and then we're going to the right Answer. Especially has been diagnosed with schizophrenia, and you're thinking of starting a medical therapy. He has been on the methadone replacement therapy, and the reason for him being on the methadone replacement therapy and white significant. It's probably for his addictions in the past, but the wild significant is that methadone is a key cause off long QT syndrome with long QT syndrome, you technically can't give you anti psychotics. But, uh, studies the research has shown that could I a Penis actually quite safe to give in this long QT syndrome? It doesn't cause this classical prolongation of the duty which could needed to ventricle Affleck. Failure could read into arrhythmias and stuff. So that is that is the key sort of concept that they need to be cut this new. This needs to be thought. Is it possible to remove this? Yeah, right. So now that we have listed, it's that it's it's called diapie. Can anyone tell me what drug you give for treatment resistant schizophrenia? It's one of the options here. Okay, fantastic. Yep. Cause itchiness the right answer. So treatment, resistance, schizophrenia. So you start off with diabetes Haloperidol that this type of it's it's difficult, difficult 2nd, 2nd generation, that first generation, a second generation antipsychotics and then you go for clothes have been as the final think, and close it being works wonders. Actually Um, sorry. Initially. Just remove it. Yeah. Who so close it? Being actually works wonders, but the only side effect that it could have a granulocyte process that we we learned quite a bit. Yeah. So what is schizophrenia? Schizophrenia is thie decrease in dopamine in the prefrontal cortex pathway. Prefrontal. It's impossible to remove this. This person. Yeah. So schizophrenia itself is a decrease in you, you ones. But what do you see? Uh, so I'm just trying knows this, okay? Yeah. Schizophrenia itself is a decrease in dopamine in the prefrontal cortex. That is, you can see here. Where is the prefrontal cortex? Prefect? Front of cortical pathway. I don't see. It ever meant an increasing dopamine in the measles pathway. And so that's why so just remember these to sort of, uh, the key concept so that we can work out. Why antipsychotics when it's first generation or second generation work or do not work. So there are four different quadrants. Ms Olympic miss a cortical nine recital and to below infundibulopelvic. Anyone knows the significance off tubular infundibulum and the drug in the previous question, Resperidone anyone knows What's the significance of this sort of tubular in front of land. Yeah, exactly. So an increase respect risperidone particularly, but generally with other antipsychotics. A swell risperidone particularly causes an increase in dopamine in the Cubillo infundibulopelvic three. And this actually causes on increased production of productive. On this productive would cause a milk to be increased amount of milk to be sort of discharge in in the person. And so that's one of the side effects off our spirit of buried particularly. But it could be generally other antipsychotics. So you know this increase serotonin activity and decrease GABA 70. So it these three step of things produces the positive symptoms and the negative symptoms, but mainly the positive symptoms here. So these are functional changes that you could notice. I'm not going to go through too much, but I really like functional neurology. And so these are the stuff that generally decreased, except for enlargement in the lateral ventricles, general decrease and hyperactivity of the brain. So we can split a schizophrenia again. As I mentioned in my in my, uh, disclaimer, this is this is based on evidence. We we don't need to stir it up any conditions, but schizophrenia could be split in the positive and negative symptoms. Positive symptoms include hallucinations, delusions as well as disorganized thought disorders or speech disorders. Hallucination could be auditory and visual. Tactile. Cost a tree, but auditory visualized. The auditory hallucinations are the main ones that you see, especially in third person, where someone is talking to them through the through. The, uh, windows are through the world. Someone is talking to them, telling them certain things. Visual hallucinations also noted, I have seen patients with visual hallucinations who have schizophrenia and delusion. The definition of a delusion is a fixed, false belief that does not correlate to the personal the person's personal beliefs. So this can be categorized as Bazaar bazaar. Grandiose excuse in mania that Helen will be covering paranoia, prosecutorial, jealousy, air. Um, it domain me a on idea of reference and Dominions is relevant to sexual sort of delusions, Um, and disorganized thought of speech, as we discussed earlier than a few different things here. Loose association, word salad, tangential speech can just the potential speech is when the person goes off topic but sort of slightly still brings it back or are in a small aspect remains. It just goes from tension, tension echolalia. As I mentioned flight of ideas just cause so fast. It's not this with grandiose behavior flying association to be talked about it. Circumstance Species. Well, don't block is the feeling that that the person has the the terminology on the answer to a certain question in their mind. But it's just a block that they're not able to articulate it. And finally, pressured speech is when you're speaking with gusto. One thing that I didn't include here is a night night moved nights move off thinking, and that basically means if you notice how a night would move the thing that they're trying to highlight it most like this, like that, like this. And so it just goes from one idea to the next to the next to the next, without any association. So that's how we did you differentiate tangential speech from nights move thinking now they're negative. Effects is well. These are emotional energy and abnormal behavior, especially motor behaviors so emotional being flat ethic, abolition, apathy. Lack of Ampyra is a lack of apathy, lack of empathy and apathy. Sorry and emotional and social withdrawal. They'll be low energy so and Adonia and allergies. So that's impact thinking. And because of this impact, thinking they'll be a poverty of speech. So that's a key 0.2 sort of identified from talk block. The way that you identify a low allergy, which is impact thinking, is through the poverty and speech. You sort of have to distinguish this with dot thought block where there's just a holding them being able to speak. They're abnormal motor behaviors as well. There's bizarre emotional responses, but the emotional responses meaning that if a certain a certain situation demands, is that an emotional response that you see generally it's a completely different emotion that they express in a sad situation. They might be happy, that kind of thing on the disorganized behavior as well as lack of goal directed activity. So these are the sort of definitions off everything that we talked about earlier. I won't go through every single one of them, but I'll leave you guys with the slides to go through it and understand every single one, right? So the way that you sort of observe and diagnose the schizophrenia is through the Snyder's first trying symptoms shyness. First round symptoms can be spit into four or jittery hallucinations, passivity, phenomenon, delusional perception as well thought disorder and all this stuff other ones that we we discussed earlier. It's just categorize into this first rank symptoms. So the treatment off off schizophrenia, our first generation second generation antipsychotics and more likely than not, second generation I use now with typing being the first choice second choice is usually sorry, haloperidol or risperidone, which work really well and plans a Penis. Well, no treatment resistant. Uh, schizophrenia is usually treated with positive because it really, really does the job. It's a very, very potent antipsychotic, UH, key things you need to measure our f. B. C's. Using these lefties as well as glucose it you need to do a weekly F B. C's to make sure that the neutrophil cloud count are not really decreasing on. That's because of a granulocytosis where the neutrophils are not be able to combat infections that the body, the body mass, is the body, and so they would go into neutropenic sepsis. And so this is what a granular cytosis is now. I deliberately missed the test You Can anyone tell me what extra test needs to be done before starting a person and and antipsychotics and, uh, stick. Yep. So in sed needs to be done. Um, so this CCG anyone where this is deceased CT shows that, uh, normally city or in abnormal, um, hyper clean here? Not really. Um, with happily mean you get a little tender debates and a PR depression, but yes, you're right. So cute. Too deep along a shin. There is a a slight amount of beauty prolongation. It's measured from the initial bit of the Q to the P wave itself. There is a bit of uti prolongation. Yeah, and so you don't You don't generally start people on antipsychotics with q d prolongation. But if you do need to start that quetiapine, it's the choice. As we saw the question just after this, just one more question. We're gonna be talking about the antipsychotics itself, and then I'll be done. Promise Island is a poor launched. All right, let's end the boulder. Majority of you guys, sort of what? A 49% off you have gone for the, which is the right on the side here. Now, initially, the, uh, the four for a pleasant presenting with depression, you go through the CBD as we discussed you go through psychosocial methods off punishment, and then you go for a biological now biological. The first line would be sexually for this 22 year old female because you're over 18. But, however, because she has a B M I off 15 Matassa Penis actually indicated and my tennis a Penis and not so sure that we'll talk about next few slides. Matassa Penis actually really good in gaining weight. And that's the That's the main reason why it's indicated here. Okay, so let's talk about psoriasis and arrows and marries monoaminoxidase inhibitors. SSRI serotonin selective serotonin reuptake inhibitor. It stops the certain in from being degraded, degraded or re uptake on day, so it increases the amount of certain in their itself. Few side effects with this a sexual dysfunction, diarrhea, nausea and vomiting, agitation, anxiety and insomnia and SIADH. Now keep going to remember is, as I mentioned earlier, citalopram because it's long QT syndrome, and so it's It's just like antipsychotics. You want to check the level, as in our eyes, say massager. SSRI is put with the norm, adrenaline bit of it as well, so it's the same same motive. Action action for serotonin as well as normal journal it and the examples of duloxetine. And when the fax see um, it causes similar is literally the same side effects, SSRI says. Well, um, when one key point that let's let's go back to the physiology off Snr is now. If you are increasing the amount of Nora General in in the snapping left, when can you know prescribing this in a row? Exactly hypertension on? The reason for this is because it could increase the amount of Nora generally in your body in the synaptic love, increasing the sympathetic tone and sympathetic response off the body, causing very high hypertension. So if you already have pre existing hypertension, it's just going to shoot writer. So SNRI quite contraindicated in the's, especially when it's mental fax, See, know Maui's morning, Um, in oxidase inhibitor. They inhibit the breakdown of adrenaline Norwegian in serotonin and dopamine. They're not really used Now. There's just because off, as you can see, they have been quite a few end of a potent Oh, uh yeah, adrenalin or a little uncertain and dopamine, and so it's not really used, but the generic stuff that they ask him. Questions are that you don't prescribe a Maui SNRI are necessary together for because of the risk off serotonin syndrome. Now Molly's could call CNS dysfunction of stimulation. Sorry, sexual dysfunction, orthostatic hypertension and make it. Now I did a bit of reading up on this orthostatic hypertension because it's quite interesting and paradoxical that a mile you would cause a so static hyper hypertension, especially when adrenaline and nor adrenaline are, are being increased in the body. But this is one of those paradoxes that that it causes. But however, together with uh contents full content suggest tyramine, it tends to cause hypertension. Um, yeah, so benzodiazepine. They're very short acting. They're short acting and long acting. So majority of them a shot acting lorazepam, diazepam, temazepam. A slightly longer thing, very long actings acting benzodiazepine are our stuff, like chlordiazepoxide, which I use for stuff like a call with drop, because off this, the duration that they can act, they inhibit indirect cava receptor agonist. So they decreased in your own excitability. You get on interrogate amnesia. Increased appetite as well is blunted effect. And if you have an overdose, you want to a B, C, D E and administer flu. Man it through menopausal. Although this is a regularly administered at all, it's really addictive, so you don't just prescribed that really need it. Try second entry antidepressants as it stays inhibition of certain and nor adrenalin in the synaptic craft. Amitriptyline, imipramine and doxepin. We saw this in panic disorder second night. They could cause orthostatic hypertension similar to the Maui's, a swell, prolonged QT central tremor. Especially with amitryptaline, you get a prolonged QT syndrome tremors. Hyper reflexia hyperpyrexia Sorry. So increased body temperature, respiratory depression and anti cholinergics activities such as urinary retention and dry mouth dry eyes because of anti cholinergics activity. If there's a overdose because off tricyclates tricyclics ability to cause a prolonged curious as a lesson long to T syndrome, you want to. You want to treat them with sodium bicarbonate, which actually treats the metabolic acidosis that it could cause. NASA is a normal dinner JIC and specific surgeon ergic antidepressant. As we talked about earlier, it's that the examples Matassa pee it increases the surgery serotonin and norepinephrine release. A key point to notice is that it is really, really useful in weight, weight gain. But as I mentioned, it could cause with this weekend because off its metabolic effects it could cause an increased amount of triglyceride cholesterol levels as well. It has some anti cholinergics properties because of this or internal and being released. And it's really good as a sleep lab slip together with topical uh, soma has it been, and so pick from could actually quite useful. I sort of situations. Last question, I promise. And a land over to Ellen. It might. Yeah. Could someone school mirror if you're there? Could you Would you mind launching the pool when the questions come up? Thanks. Yeah, right. Let's call it. They're fantastic. So majority 29% of you guys have gone for IV fluids, followed by 25 confidentially. So this is female was in the emergency department. Confused, agitated in fibro. Uh, she has a high temperature. She has started on haloperidol recently for acute psychotic episodes and her past stroke history. Saint John's wort. Now the posture drug histories in John's wort is actually a red herring. Now, with the two conditions that actually could you put in the chart? What are the two conditions that were trying to differentiate between here based on the red herring, as well as being started on the haloperidol, certain it's in room correct buses and as a neuroleptic malignant syndrome. So serotonin syndrome generally is caused by people who are taking an increased amount of serotonin. So as we discussed in the previous few slides, Maui's SNRI SSRI is combined use of them as well. To get as well as together with Saint John's wart actually increases the amount of serotonin in your body that could concert on it syndrome. But she's not on any under SRS. Action varies that cause an increased amount of serotonin. So haloperidol is the one that we need to be concentrating on here. Caliber dollars, an antipsychotic. And since he was recently started with for the acute psychotic episodes through the right answer would be that we're thinking about his neurologic malignant syndrome now than traveling is the treatment off a neuroleptic malignant syndrome. But initially you always want to ABCDE IV fluids first, followed by Dantrolene. If required, you never want to give a drug if they don't require it. You always want to see a conservative management first, so fluids, always a good option for both serotonin as well as neuroleptic malignant syndrome. And then you give a dental, dental and actually works inhibitor inhibiting calcium Release into the the corner and the contractor muscles so it decreases the contract contractility off the muscles. Uh, because in your elected malignant syndrome, you noticed them being very, very rigid. So that's 100 Dantrolene works. So distinguishing between serotonin and syndrome and neuroleptic malignant syndrome, it's caused by all these stuff. It's because of the neuromuscular activation junction activation. You'd see confusion, autonomic activity, the hyperactive bowel sounds on this would be contrasted with normal or slow balls off neuroleptic malignant syndrome. You can use a separate separate captain or chlorpromazine. Super happen is a serotonin senator serotonin, ergic antagonised, whereas for your electric malignant syndrome could use dance really off from a crickety, which is actually a dopamine antagonist. Uh, Bromocriptine is a dopamine for a neuroleptic malignant syndrome. The key point to note is that you would you would see a race creating kindness because of rhabdomyolysis in neuroleptics malignant syndrome. Um, yeah, and so there would be autonomic give the And as I mentioned, Dantrolene combats this muscle rigidity here. So I just added a few post lecture notes for you guys. Hold sectioning thing. What are the different sections? And the indications have added devia labels, psychiatric disorders as well as for BS. I was actually going to bring this up in the session, but I thought that it might run over time, as it already is. So I will hand it over to Alan. Uh, and you guys can can take a look at the post, actually. Notes when you fill in the feedback from Ellen, you wouldn't get it rechecked like that. Too many breaks. Good. It's ticket to Liberec, and then we will check, uh, check the, uh Any questions? It was not that working. A pretty it 40. Yeah. Ellen has a few concepts to cover, so I want to be able to get through suspect weaker. Oh, that share my screen. Oh, yeah. Should we start in a minute? Yeah. Sounds good. Uh, just want to make sure it's all working. I hope that was understandable. Uh, the guys on the on the call. Uh, yeah, I was sick. It was It was It's a really, really tough topic to cover it. Just because of the, um, set off, uh, the touching nature. You're not touching each other, but sort of I don't want to call in and say the wrong thing thing. As we we we did have a few sort of people complain about complaining about the control. We give disclaimers. So hopefully, um, it was useful. Yes, sir. Just just that disclaimer carry spoke of this session is, well, Allen stalkers, others they'll still be some sensitive topics covered in Ireland. Stoker is also just be mindful of that. So yeah, it is. It is quite a tough have sort of concept of cover without having stereotypical are certain signs and symptoms that you need to know. So but the key point didn't notice that difference from patient to patient. It really varies. And these are the common symptoms that you would see. But the treatment thesis Tums everything varies from patient, patient on, and you need to consider their past medical history, passing background as well, whether there's any traumatic experiences and try to address all of these issues when I treating a patient rather than going to do just straight to, uh, medication. So psychosocial stuff. Um, yeah, well, that we'll talk about all the a lot of these principles again in the Oscar. To use is only start a psychiatry posse. It's very, very important. O osteo stations, like a tree. So make sure you turn into that. Yeah, that's that's in March, right? Yeah. A lot of lot of funny about obsessions. Fund. Yeah. And you know God, Yep. Can you see my slides? We'll give me a second only 37 screen. Also, while I've got you down for those tuning into the little mark examined Sunday, make sure to download the be box up. Well, I put out a message on social, but chronically there going on there are other around mentioned just the end there, please, that we will carry forward the disclaimer for this session as well. So if you guys do find any sensitive topics, please do that. If you'd like to reach out to anyone or anyone in your skis a team, please do reach out to us as well. So we just launched the pole here. Oh, end of pull back and share the results with you guys. Eso the majority of people have gone for see in this question which would be the right answer. Eso if you just have a little closer look at this question. We have a 21 year old woman who's bean, um, brought in by a flatmates on this is often common with this kind of presentation that somebody associated with the people have to bring them in like their. If their patients under the age of 18, they're more likely to be living at home. So I'm not be their parents. Or in this case, the patient is leaving with the university flatmates on. We see that there's a seven day history off acting odds, which is a zoo. Guys know characteristic off mania, which which which happens when we have decent elevated mood symptoms and psychotic symptoms and social function impairment symptoms lasting over the course of seven days on. We also see that they've had very little sleep, which is also very common in this disorder on, So this patient actually has bipolar type one disorder. Now, in terms of where bipolar type one disorders treated, it can be treated in the hospital, and it can also be treated in the community. So patients who are adults, um Andi, known to the mental health care. That mental community mental health team can actually be treated within the community itself, so the's patients will require an agent referral, whereas if it was just presenting with hyper mania, then they only needed routinely. Spiruline Andre wouldn't commence lithium within the community. So if we talk a bit more about bipolar effective disorder, then so we have two types of bipolar effective disorder. Type one and type two on in type one. This we mentioned on the We get mania as well as the difference of symptoms and in time to get hyper mania. And we also see that in the depressive symptoms, associate it with bipolar disease. In Type two, pilots sees the patient often. Not always, but often do you get a very severe depression. You can also see on this graph. The normal progression of depression is initially they get very low symptoms of mood, and as they started on the medical therapy within four weeks, they should see a good response, and then for a long time their plateau did, and then they can have certain triggers, which once again cause them to experience that low mood. It's just important notice that there's a difference in the I. C d 10 on DS DS. Empty five. Classification of bipolar type one and type two in I CD 10. Basically, they they need to have at least two mood episode, so they need to have one episode of elevated mood of one episode episode of Low Mood. And then one of the elevated mood has to be your last one toe hypomania mania. Where is in a bipolar type one in the December 5, you need to, um, so that they had no need to be one presentation off the You just need that elevated mood to diagnose in the D. S m five criteria. So if we look it bipolar effective disorder just compared this is just literally a 70 table for you guys. Um, yet once again, we'll mention that, but mania last for seven days, and you also get more. That function impairment is more prominence s so often it will affect the patient's social life as well as their work. Where is in hyper mania? It's not that much of a factor on also they're on, but the depressive symptoms and more severe in the bipolar type two in terms of treatment, then on. So when patients are initially found, if they're agitated and they're unable on there, um, and they, they don't require they don't want treatment. Then initially, it might be good to use a. Initially, we use an oral answer. Kosik agent. Typically on this could be a Lantus mean, which is normally used to this line on Ben on. Then we'd want to stabilize the mood of the patient. However, if they're not agitated and they're willing to receive medical therapy, which is no often the case in these patients to their grandiose thoughts and the delusional believes, then we can start the more lithium. So let him initially. It's when patients first have first diagnosed with bipolar disorder. They start on 300 mg on that on. It's given three times a day on this convey on raised all the way up to 1800 mg per day. Eso yeah, initially, when they're so, they'll have a maximum dose of 900 mg. If lithium is ineffective, then we can also use other agents, so sodium valproate is often given on day. If the patients didn't tolerate this either that we can give the lamotrigine on. In addition to all of this, they may also be given a cognitive behavioral therapy. And talking therapies on these actually don't think is actually don't help like they do in depression. What they do is they gave patient a coping mechanism so that when when they do start to feel these kind of elevated moods on, they do start their depression on. But it's, um it allows them to coca bit better, understand what's going on with them so that they can seek treatment. However, unlike and depression, it doesn't have that much of clinical effects. Um, you could also treat coexisting conditions as well. So if you move onto the next SBA, I do apologize. This SP is, and as interesting as the other ones have been, more of a cut, some dry one so will end it there. So I think the majority of people went for 12 hours in this case. So generally, if patients are stable, um, generally, if patients are stable on, but they need a dose increase in their lithium, it can be checked one week later. Um, however, if we do start them on the drug initially. Then we do check the drug within 12 hours. So if they would give administered at nine AM in the morning, we want to check the levels and nine PM However, patients who are currently stable there needs to be checked one week later. Um, so lithium toxicity then. So basically, we have the when we give lithium initially, as we mentioned, so after 12 hours will be checking the bloods initially. Then we'll be checking it within one week on disease. Lithium has, um, has a long past mo half life on. If we have a concentration above 1.5 millimeters liter millimoles for Lita, then we can start to get the side effects and the toxicity. So initially, patients may have a course tremor. They may also be hyperreflexic on acutely confusional on. There's a number of things which can precipitate this, as mentioned in this kid. The case Then we saw the patient were had experience. Experiencing green off was had normal really function. But if patient, as you can imagine that renal failure, then this would be a little toxic and happen much quicker. And also, if they're using drugs like diuretics, um, on a sin. Hibbitts is so in terms of treatment in acute toxicity, we would use a humidifier, Lysistrata and maybe sodium bicarbonate as well. But in, um, multi moderate toxicity when the symptoms aren't too severe. If we just, um, off do fluid resuscitation that the patient should should be okay, So I'll be launched the pole to send it, then share the results with you guys. So in this case, we have a patient who's undergoing alcohol detoxification on. We see that he has a history of Patrick failure on which of the following medications is most appropriate in this patient. So no, I think the majority of people went for a on Normally, it would be a chloro diazepam side. However, in this case, because of the hepatic failure, um, lorazepam is used first line. And that's because it's not metabolized in the liver. So this is a quick slide that I added about opiate overdose. Jesse, just you know that when we suspect opioid overdose and patients who present with cardiac respiratory depression, we treat them with knocks own on DM. Also, in people who have who have opioid dependence on, then likely on, they want to I stopped taking opiates. We can support them. A number of ways to get the Blue Cross, often methadone on Diovan. Eight. The behavioral therapy as well to help change their patterns of thinking. Say, this is what we were talking about. So alcohol, Syria, alcohol, detoxification. So in terms of alcohol on detoxification, so every region might have a different local protocol how they're generally so alcohol assistant. But all is used in patients who drink more than 15 units per day or haven't ordered score of more than 20. However, this conveyer, depending on the patient and the symptoms that they they present with on initially, we wanna continually monitor um, them what the See what scoring in order to give any additional therapies that are required. But but as majority of people, this was and today and this is what's usually use an alcohol withdrawal, um, in the medication's helping avoid relapse then so we can give them a camper toes, and that actually inhibits us how the high dehydrogenate is on. Basically, when patients do drink alcohol because unable to be broken down, they have a lot of side effects, like vomiting and nausea. You just got to be careful with this because they can have a lot of drug interactions on Also weaken. You give them disulfiram, which helps them remain, which helps them, which reduces that craving. Um so alcohol withdrawal on alcohol decreasing thie levels after somebody has an alcohol dependence is a It's a very tricky and fine balance s o if you guys have been to the psychiatric clinics and seen the Simpsons dependence clinics on. But you'll see that win with opioids and other, um, addictions, the the consultants. So you know, they're more happy for the patients that come off it a bit quicker, but alcohol is as slow as possible, whereas, you know, every week they might only be patient might only be reducing half a unit or units on the patient. Is safety netted over and over again? Because as you guys know, that alcohol withdrawal can have some very toxic side effects. And unlike many other many other substances can me to death. I'm so in chronic alcoholism we see diamond deficiency on da fire mean is very important cofactors for a number of reactions. In order for the production of ATP to occur on base um, Actually, the timing deficiency leads to the areas in the brain which house, um, hi. Energy requirements toe actually have tissue, ischemia, and death on this is actually what eventually leads to Vernon Keys and course a corpse. So in Vernick e Centrum, we see the the common triad known as the Ace Try had on. So initially we have acute confusion. A taxi here on we can also have nystagmus, so that's seen about one third of patients. However, this broader ocular motor dysfunction is seen in more patients. However, they're all three of them occurring together. Isn't this carbon? Then, when we have a long time of vernick ease on this continual finding deficiency, eventually it can can I can turn into course I cough syndrome, which is characterized by amnesia configuration on by closest. So in a very Nikki course, constant. So basically as we mentioned the pathophysiology was that it's a cofactor the enzymes to help help produce ATP, and we need about more than 1 mg per day in men. We need about 1.2 mg, and in women at 1.1 have in pregnancy is slightly raised. It's about 1.4 mg a day. Um, so in terms of clinical features. So the ocular motor dysfunction we can have in Vernon Keys on death allopathy are my stagnant Yes, on the lateral rectus, poor erupt lateral erectus palsy and then the congregate games palsy as well on the terms of clinical features. Off course, Forbes, we only mentioned confabulation. So that's the stories. They, um that the patients say to, um, fill in the gaps between the times that day, forget their memory and in terms of memory deficits, they can hard until grade unrecorded memory deficits in terms of the diagnosis. Then for Vennochi syndrome, we clinic is and careful opathy. We can actually use the cane criteria, which is two of the following s. So I'll let you guys read that. And then obviously we have the investigation. So it's important to do MRI on. We also look at their red cell transit Keto lazy. So for treatment, we give IV five min on. We give two ampules normally, um, over 3 to 5 days on, then this compress longer, depending upon the patient on If the ondas we mentioned before, if we leave it untreated, then that's where we're likely to end up with, um, Korsakov's So in course college. There's no there's no treatment which will reverse symptoms. However, we can provide supportive care. We can give the patients that we can give the patients, carries help with the activities and they daily living. So when the next question now think we can pull that the rash at the results of the guys? So we have a 77 year old gentleman who comes there to the emergency departments on day, um, for a full just after midnight. There's no active bleeding and he says he can see birds flying the room so we can see ah hallucination on. He has dementia, so we don't know what I could venture The patient has. He also takes control. Being to continue being can also cause the quetiapine can also cause hallucinations. However, in this patient is most likely to be delivery. Um, this is because that dementia actually lowers thie threshold for delirium on Gwen the's patient. When patients who were quite unwell of a change of setting on have some cognitive decline, they can get very. They're very low threshold for becoming delirious. So if we compare dimension delirium then, so dementia often has very insidious on slow onset combat delivery. Um, on delivering, which is quite abrupt on deviously in delirium, we might see a fluctuating in the cognitive ability of the patient. However, in dementia, there's a slow, slow decline on deviously. It's a much more rapid onset, as we mentioned before, so you can go through the rest of the table in your own own time. But it just is a quick summary of the differences between dimension delirium, when I important thing to know is the patient's thought. So in dementia, it's often impoverished on down in the area that the patient's often do did and disorganized. So that confusion helps you, especially it's seven change to where the patient's baseline is. So this is the table comparing the different types of dementia. Eso, the pathophysiology as you a Z guys know, is very similar for Alzheimer's disease in terms of the tower protein obligation and this also seen in the frontal temporal dementia. And also you have the neuro fibers, tangles made of the beat amyloid plaques and Lewy body dementia. Then you see the alpha um, sin nuclear protein deposited with the substantia nigra and then in basketball mention you have the vascular causes on. They often have their have a history of hypertension on day may have had a couple of strokes in the past in Alzheimer's. Them received that the short term memory loss is the most prominent thing. Where is and friends of temporal dementia? Because the frontal lobe is associate ID with the personality, the patient's personality slowly drifts a Lewy body dementia. The key distinguishing features are the visual hallucination on the patient's confer. 10. She have parkinsonian is, um, as well on then. So for all of these patients who want to do a full investigation, see if there's any underlying cause of their of their confusion. You want to assess their mental state's on doll. So if four. So we want to get them adapt scan, especially if it's patients at a younger onset. So we have the medical management here s O for Alzheimer's disease. Does a pill on do Gallon to mean our first line s the's a first line, and then momentum in the second line for frontal temporal dementia? Even though you can use medications that actually doesn't affect the course. It doesn't actually improve the cognitive decline of the patients and blue body dementia. We have a stock only nasty raises. Which of the first state of treatments on, then in vascular dementia. We want to protect them against the or the risk factors off having another vascular event. And it's on the previous light contrary. You know, the intermittent is the back now. Yep. Sorry, I was manipulating the pole. So if we end up all there eso in this patient, we see a patient attend the emergency department with severe abdominal pain on They've already done this on. So they they no signs upon examination and investigation off. What is the underlying cause of this abdominal pain on to see if the patient has done this three times in the last two weeks. So the majority of people went for D, and that would be correct. So this is malingering. So if we look at the unexplained symptoms, unexplained symptoms are going to these is actually an extra criteria more than there's no other diagnosis. Where which I haven't hear added here, but eh, So it can be broadly spit into voluntary on involuntary admission. So these patients patients were on this side of spectrum will more likely they want to be admitted to the hospital on this because they're they're looking for something so they may want to play a sick role. So if they want to play a second, they want to be, they want to have an illness or you know they are. They're they're looking to be diagnosed with something, so that's often seen him. That's Munchhausen syndrome, or factitious disorder. I'm when the patients want a secondary gain. So if they want to sue somebody and get, um, um on declaims, for example, if then the car, uh, a crash they had whiplash on. They want to gain money or they want to. They go into the hospital on they're looking for drugs. If they want some kind of secondary gain of their presentation, that's malingering. If we look at the eso, the involuntary side of things, so patients who come in and they may be bought in by somebody else, So patients who are are really preoccupied by their symptoms, they want to diagnose that they were. They were very anxious. They want to diagnose themselves or something, so that's hypochondriasis so actually, in my last placement in psychiatry, I saw a patient. The last history I took was a patient with hypochondriasis is on. This middle aged gentleman was, um, was affirming the air was telling all the doctors that he wanted to be tested for kids see a cop disease on. So they did MRI on there or the two different consultants explains that the fact that it's very unlikely and this gentleman, especially with the progression of the disease in very abrupt cognitive decline And this this gentleman was pretty much had most of his cognitive, um, cognitive faculties intact. He was still unable to take in bed. That negative diagnosed the fact that he didn't have the day that he didn't have this, So he wanted another investigation to see, and he was very anxious about whether it would come back as positive or what else he could do to prove the symptoms. However, um, these patients, when you show them negative results and explain it to them, they then they with time they become, they become, they can accept that which is what separates this from Munchausen's on. Do we have the patients who have neurological symptoms, which are unexplained. So this is a functional neurological disorder or conversion disorder, and then patient to have physical symptoms on bus Samast is a shin disorder. If we end up pull that. Yes. So this question said majority of people have gone for, um b, which would be the right answer. Um, so we're actually just before we talk about this question, we're just going to look, it's, um, eating disorders on first, and this can be quite sensitive topic. So if anyone is affected by this or no, somebody is affected by this. Uh, please. Uh, um um, we you have our sympathies, Onda. Things can be a sensitive topic. So pleased to be aware we don't mean to offend anyone when we talk about this, and we're just doing it to try and inform you guys. So first will have a look. It anorexia. Um, So patients who are anorexic, um, contentment simply tell me the main way how to distinguish between anorexia, bulimia on the charts. Who who? So Yeah, I think, uh, people have said purging habits. Eso Yes. So there's two ways which we can do it so patients can have periods in habits and believe me A which are unlikely to be seen in our anorexia but may also be president. This specific subtype of interaction of OS and I should say the full name anorexia nervosa went discussing it. So yes, it be, um, I'm purging habit. That's fantastic. So patients who have anorexia generally have a bm I under the under 17.5 on Brexit can have a lot of a lot of complications, such as bradycardia and hypertension. Big, his associate of electrolyte abnormalities, the's patients on physical examination. They may have enlarged salivary glands. They may also, when you see them, they might have very reduced muscle boat. Um, in terms of skin. If you set the skin, they may. They may have quite dry skin on in terms of their head. They might have a brittle hair, and they may also have. You may also be able to see on the nails, Um, and in terms of the hair on the body, it might be very well be very fine on do. They may also have a road, a tooth enamel due to the deficiencies, so these patients can have often have hypo clean hypocalcemia which we'll discuss it a bit more detail in the next slide. They they will also have low FSH and LH them actually have race growth hormone and cortisol on their haven't embraced here impaired glucose tolerance. So they may have a low t three, um, and would. And if we look at hyperthyroidism, the difference would be that they have weight gain. Whereas in anorexia you'd see that the patient has a very low be, um, I on in order to diagnose this, eh? So you need to see that the patients have a much lower than the regular energy intake that that's required. They may also have a gun substantiated fear of gaining weight. Um, or they might be taking measures to induce weight loss. Where is it it's taking by a pills that they buy on the Internet or some other means. They were also don't have a good perception of their weight. So they may, they may say, you went in the consultation with do they may suggest that they are overweight on did. They're unable to understand why, um unable to perceive their weights compared to others, and also they may unable to see their negative aspects of having such a low body weights in patients of prepubescent on. They developed anorexia. You might see delayed puberty on Also, we can see it within endocrine disorder. We can also see on the crime disorders such as a menorrhea. However, um, this is actually not part of the, uh seeing and menorrhea on endocrine disorder is not actually part off the diagnostic criteria. Um, I will put it put a just the slide that in the revised three ds and five this was in December for Do apologize in terms of treatment then. So these patients have very specialized therapies, so initially they'll have the, um they'll have cognitive behavioral therapies. So this is so in adults they'll start off with cognitive behavioral therapies on day. Also have the mantra treatment, which is quite effective on any Any treatment for these patients Will will be under specialists. Review um, in Children they have unrecognized focus family therapy on. But that's ah seems to be more effective. And believe me, a then, as people mentioned, so the's patients have, um ah, higher beer. Might They may often be normal weight's, so they will definitely above 17.5. These patients, like in chronic alcohol use, is, can have brought it gland enlargements on bacon on dumb as we mentioned purging habits Alias that these patients may have Russell signs, Um, and so it's very important to check the check the hands of these patients during the physical examination. So in terms of, um, treatment for this once again, we must refilled them to the psychiatrist specialist on day. So initially, they tend to get the self help just like an anorexia on. They'll try that for four weeks, if that's an effective than they move on to the the behavioral therapy on, um, recently, um, fluoxetine. 60 mg or high dose fluoxetine was licensed for this. However. It's not very frequently used, Um, but it is another line of treatments. So this is what our question was about. A repeating syndrome. So So in patients who are starved, they often eso when they when they present, and we're giving them the rehydrate airway. We're replenishing their electrolytes on DPA, avoiding them the adequate energy intake, using the nutritional supplements and on fluids with the correct electrolytes and vitamin replacement. They can often describe that they can often develop high school foster team here. I put my knees, ear, and I purkinje so this can lead to a variety of symptoms. But it's it is very severe on patients who have a very low be, Um, I have had a lot of weight loss within the last couple of months who have recently undergone major surgery, which leads them having a very high energy intake. Um, however, that able to eat for several days on then patients who already have an electrolyte abnormality leading up to this are at the greatest risk off developing receding syndrome. So what we see is initially so the patients have, um so initially what? We see it. So the reduce or Alimta take leads to decreased levels of glucose on. This actually leads to lower incident levels on Dehiba Lupricon levels. When refueling happens then so the insulin is released from the beat the pancreatic cells and that actually, um, on that falls and regulation with the regulatory hormones on. So basically ah, a lot of glycogen on protein is very quickly 10 size on. Also, they're, um on also there, four states magnesium Bittermann, then become depleted. We also have we can also see in these patients very low finding levels on do if patients that have previously, um, hot history of Vernon Keys, then very important, one of these patients. Stop them from developing course cough. So, um, as well as that. Excuse me. Sorry. Um, as well as giving the the phosphate, the magnesium, the potassium, it's also important to administer these patients proper. Next. Next work. We're just wrapping up now. Just a couple of slides left. We're quickly looking at personality disorders. Eso we have personality disorders can be split into three different clusters. So cluster a, um, our patients, where which often described is weird, odd or eccentric. Plus D uh, B patients are often wild, dramatic and emotional. Onda Plasticy patients were very worried, very anxious and very fearful about about themselves on. That's their This all comes across in their personalities. So in terms of prostate patients would be There's three main criteria is here, so we have paranoid patients so paranoid patients are constantly suspicious of others. They have trust issues on day, often accused others without proof. Please excuse my spelling mistake on, but they're very jealous of the people around them. schizotypal people, then our camp there. These are the characteristic, very ordinary centric people. They might dress very different to the norm. They might come in like magical hats and fancy dress on Do they have thinking on? It's very hard to follow their thinking pattern. Um, in terms of schizoid patients, they are a Threat IX. They don't really I'm care too much about others. They prepare. They prefer their own company on, Do they? They actually voluntarily, um, that we draw themselves from from, um, from society on down, um, from social relationships. In terms of plus to be, we have four different times here. So what's a very common one that we see on exams its borderline personality disorder? On these are patients who have abrupt mute things hand to have, who are very emotional of the patients often self harm themselves. If you are in ah, in the if you're taking a history from these patients, so it's very important to ask about self harm. They also very impulsive, so they might describe a lot of situations which they put the clip which they deliberately put themselves in harm harms way on, then unable to control this on game. I often describe having multiple relationships with multiple partners and very quickly changing between those on. We also have history, nick personalities. So these are patients who have very who have the attention seeking behavior on these, normally very extroverted on day the's. They often are very sexually inappropriate and assault. The Marilyn Monroe essentially have this personality. We also have patients who are not cystic. So they're they have grandiose Stort. They think this periods everyone. They have an inflated ego. These people are actually often do very well in business, but they often have very low self esteem of themselves, which is what leads them. Teo have this elevated to personify this elevated ego, and they have a need to be admired by others. So our last light of the evening and percent of disorders So we have avoidant um, dependent on Bob's obsessive personalities so excessive personalities rebound considered already covered Alia. So we'll just quickly record avoidant and dependent personalities so forth. And, um um for the spelling mistake again here about social inhibition so bored in facilities once again, they're not very well integrated society. They have a fear of rejection at the very sensitive to people around them, and they're negative views. However, they do desire, companionship, dependent personalities. They also need somebody. They also there's like companionship. However they their their differences. They want somebody to cath of them. They were on. So they often have relationships where they're enabled by the people around them on. But they often have very poor confidence. So that pretty much wraps up. Um ah, they're my side of psychiatric presentation, so thank you very much. Every for joining us today. Yeah, thank you very much.