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Yeah, so, hi guys. Uh welcome to another installment in our Finals Easy series. Uh My name's Nish. Uh I'm one of the co-founders of Oscar Easy and uh previous he head of education, I'm also finally a medical student and incoming um S and P doctor and I'm very interested er, in psychiatry myself. Uh One of my F FT uh foundation rotations is in psychiatry. So I'm very excited to uh teach uh today's session. Er, psychiatry is a very interesting field, um, very, er, complex, er, mental health conditions that we're gonna be talking about. It's gonna be very interactive. I got loads of, er, finals, er UK MLA um style, er S single best answer questions for you. All the conditions covered in today's session are in the UK MLA curriculum. So very, very important conditions to know uh both your exams and for clinical practice as well. And uh before we go into the actual er, teaching today, I just wanna give a bit of a important disclaimer. Um So as this is a psychiatry teaching session, uh we are gonna be talking about very um important mental health conditions. Um namely things like depression bipolar disorder, psychosis, suicide, self harm, eating disorders, substance abuse and child psychiatry conditions like ADHD autism. Um and want to give a important um disclaimer. So individuals diagnosed with mental health conditions will have their own experiences of their illness, which might not be fully represented in this session. I'm I'm a final year medical student, uh incoming S AP doctor. So I'm confident in my own knowledge, but I'm not an expert. I'm not a consultant psychiatrist. The content is for education purposes, only not intended to be used for advice or substitute for any formal um medical teaching information in this teaching session is based on UK guidelines UK UK Malay, um curriculum. Uh Please check local guidelines, er, for official information, official um guidelines like us, I CDD DSM five for things. Um If you find any of the information in today's session, very triggering or uh disturbing or if you feel, er, I've said something that's inro for you guys. Uh feel free, please feel free to uh let, let, let me know you can private, message me after the session or feel free to leave the session at any time. I'd be happy. We, we'd be happy to sign post you to any, er, relevant um support services um as well. Um, just an important disclaimer for you guys. Uh I hope you guys do find this teaching educational and uh yeah, I hope you enjoy. So we're gonna go into our first uh single by Santa question. But I got, we got quite a few um questions to go through. So we'll give around uh a minute or so if you guys to answer each of them, um Ellie, can you share the launch the pole? Uh call it that? OK. Uh Interesting. So, uh most of you have chosen d quite a few of you have gone for E as well. So, correct answer here is actually uh e um electro convulsive therapy. Uh So difficult question to start up with and uh purposely tried to sort of mislead you into picking um D. Um So there's sort of a bit of exam technique here. So we got a elderly man uh who's presenting with um low mood. So severe depression, severe weight, significant weight loss, OK. Very, very important 9 kg of weight loss over a, over a one month period is huge. Ok? Very, very clinically significant. Um I've told you that he's previously responded to an antidepressant. OK? Tricyclic. Um but the, the key, the key sentence here is the er, he's not eating and drinking. OK. So he's had very significant weight loss, he's not eating and drinking. Um Mental state exam shows that he has um signs of um de depressive disorder. Ok. He's got, he's looking down giving very brief audible responses classic for um and depressed patients. I've also hinted at possible psychotic symptoms, ok. He's having potential um auditory hallucinations. We haven't gone too much um, I into it. Um, so in terms of the answer options. So the key thing here is that, er, this is very life, this is life threatening depression. Ok. It's life threatening because he's, I've, I've told you this patients have already lost huge amounts of weight. He's not eating and drinking and that's a life threatening feature of depression. Ok. If they're not eating and drinking, they're having significant weight loss because of their depression, it's a life threatening um feature they need to be referred for emergency um sort of er significant treatment which is electroconvulsive therapy. Ok. So ect it's needed for very severely depressed elderly patients who are not eating and drinking and they need a rapid uh intervention. Ok? They need something to improve their mood significantly to try and improve their eating and drinking. Ok. Might if you went for a psychotic therapy and that could potentially be started along the way. Uh Potentially if they do have psychotic features with their depression. But the most important step here is EC T therapy. Ok. The rest of them is not as appropriate. CBT is not gonna address your acute problem, tricyclic and S MRI s uh might be considered further down the line, but that's why is the correct answer here. My question also for the previous question E CT can also significantly help with um psychotic features of depression as well. So the CT can also be considered a treatment option for the psychosis um as well as well. It will call it the OK. Majority of you have chosen um an option B and that is the correct answer. So well done. So uh this is a bit, a bit, a bit more of a box basic um question you'll get in terms of um antidepressant pharmacology. Um So we got a uh middle aged man done with core features of depression. OK. Low mood anon lack la lack of sleep. He's on sertraline, 50 mg with his standard um starting dose for men. And I've told you that he has, his symptoms are starting to improve. So his, his mood symptoms are improving. He's his function is improving as well. He's gone back to work. He feels much more positive about his life. He's been in responding and tolerating well from the sertraline. So progress is basically asking what do you do with sertraline or antidepressant therapy in general for patients who are responding well. And the key thing here is not to pick, stop the sertraline immediately. OK. What, what's the problem with um stopping antidepressant therapy straight away? Can you guys tell me in the chat? W what's gonna happen? What, what is the risk? Uh if you stop it straight away? Uh discontinuation? Yeah. So that is a, that's one risk. Uh you that can happen in some patients you can get um serotonin discontinuation syndrome, which only happens in some, a certain proportion, the major reason is because of the risk of relapse. Ok? Er, if you stop it suddenly there's a high risk of um rel relapse. Ok. So the key thing is even if you're starting to feel better with the therapy, um you shouldn't stop it straight away because there is a risk of relapse happening for um further down the line. Ok. So you need to extend it um for six months. And the key thing is you, you're not gonna reduce the dose with it in the, in the six months following. You're gonna keep it at that same 50 mg for an additional 60 months. And then once the patient's mood is stable and symptoms are stable. Uh after six months of additional therapy, that's when you start to taper, taper, taper off the sertraline. Ok? So let's talk about depression and it's probably a very uh um it's probably a condition you're very familiar with and feel confident in understanding. So depression, er the key things to remember in terms of the symptom wise is to think of the core symptoms. So, Anna, you know, uh loss of pleasure and things that used to um that they used to enjoy low mood. Ok? Over two weeks, history of low mood and loss of energy. Ok. So fatigue, those are core features of depression and all these other symptoms are, you know, you, you're gonna pick up from your history from things like lack of concentration, persistently, negative thoughts overly guilty about things and really, really important in your history and, er, a history of any, um, depressed patient and any psychiatric histories to ask about, um, thoughts of self harm, suicide and obviously suicidal ideations is uh an important feature to ask about in depressed patients and always think about physical symptoms as well. So, sleep disturbance, um, in depression, er, you can get patients who are both having lack of sleep. So, insomnia or sl sleeping heavily, um classically in exam questions, they'll give you that patients are waking you up really ear early in the morning. Ok. Uh Remember depression, it's a clinical diagnosis but uh you should tend to a, you will tend to do what you want to rule out physical causes. Uh Can you guys give me some conditions which are uh relate uh can mimic depression, uh low mood symptoms. Uh All all these different symptoms of depression. What kind of physical conditions do you wanna make sure you rule out? Yeah, hypothyroidism is a big one. Ok, a thyroid function test needs to be done in everyone but you can also do um like other people saying hypercalcemia as well is a good one anemia as well. So you do tend to do a full blood count as well. Dementia is a very good diff differential. Um so especially in elderly patients, often it goes the other way around. Depression is an important differential for patients you suspect with cognitive impairment it often gets, um, er, it doesn't get diagnosed enough. The s sort of um de depressed elderly patient often gets diagnosed with having cognitive impairment instead of depression. So, er, very good differential there. Uh B12 deficiency, fibromyalgia, anxiety, all good differentials um as well. So again, uh you need to do these basic blood tests to rule out some of these physical causes. And we've talked about the treatment options. So, antidepressants, um we'll talk uh talk about them on the next slide. Psychotherapies are first line. So CBT um I A PT. So, interpersonal therapy, um sleep hygiene. And obviously we talk about uh electroconvulsive therapy. So this is a procedure where they sort of basically um um exert shockwaves into the brain. It sounds scary but it's a very safe procedure. Ok? It's a very effective treatment for depression, but it has many very specific indications. Ok. Like in the question. So if they have life threatening features, ie they're not eating and, and drinking or they're having significant um self harm, um suicidal um features or they're having psychosis as well, treatment resistant depression. Uh These are all very important um indications for ECT. Ok. Other things like if they have very severe psychomotor effects from their depression or stupor and things, those are all indications for ECT. So, antidepressants, uh pharmacology, er this slide is basically summarizing most of the key finals knowledge you need to have for antidepressants. Ok. Er, there's five classes of antidepressants. Um, SSRI S are your first line um, choice, er, for antidepressants. Um, sertraline. Um, in um adults generally in Children you might tend to go for flu FLUoxetine. Um, key thing to remember for your both your finals and clinical practice is you need to counsel patients on that. It'll generally take up to six weeks uh for patients to notice um effects. Ok. And in that initial period, that initial 1 to 2 weeks as well, their, their mood symptoms particularly can get significantly worse and if they have any suicidal ideations as well, that can get worse in that initial period. So you'd need to warn patients um about that. Um rides tend to be tolerated the best um by patients and have less side effects compared to the other ones. But important side effects to be aware of for things like gi upset insomnia and sexual dysfunction as well as very, very common in patients taking things like um sertraline, uh paroxetine is teratogenic um as well and uh have a read of some of the other antidepressants and uh side effects as well. Uh Again, like I mentioned, antidepressants need to be continued for at least six months after resolution of symptoms for that first episode. If they're having a uh second episode of uh depression, generally, it'll, it'll be continued for around two years. Ok. Uh For antidepressants, they can also be augmented with things like lithium or antipsychotic therapy as well. To try and increase the effects or if they have things like psychosis as well, um With their depression, these can be added in as well. Next question. So that, that covered uh depression. Hopefully, you, you guys are much more confident in that. If you have any questions about any of the conditions, feel free to leave it in the chat and I'll try and answer you as we go along. Or if you uh if uh if you have any questions, just leave it at the end, I can spend a bit more time trying to answer them. Uh Someone's asked, when do you continue antidepressant for two years? Uh Yeah. So uh generally after, if they've had a second um attack or a second episode of um mood, mood disturbance, depressive episode, then you generally continue it for at least two years. OK? If it's just an isolated uh depressive episode at first off first time and then it'll generally be just an additional six months of second attack, then about two years. If they're having multiple episodes, multiple depressive episodes, then generally they're gonna be on um antidepressants for a very, very long time. OK. It'll be um long term antidepressant therapy if they're having multiple episodes. OK. I'll end the pole there. So uh most of you have gone for B and that is the correct answer. Well done. So, um this question is uh basically, we got a patient who is uh presenting with an episode of mania. Ok. So got a young woman, uh, detained for attempting theft, er, got history of abnormal behavior for the, for two weeks. Um, not slept in four days. Ok. If you can try, imagine yourself if you don't sleep for four days, how are you gonna be? And this, so not sleeping for four days is clinically, um, significant painted a room twice during that time span. Ok. Um, spent all the savings on online shopping and lottery tickets. Ok. These are all just painting the picture of the abnormal behavior that's been going on. Er, uncooperative combative claims. She has a divine mission. Ok. So we can start to think that these is all sounding like an er, like mania. Ok. So you're having um er complete lack of sleep, increased energy, complete un un inhibited spending. Um So spending all all her savings in a very short period, that's obviously clinically significant and she's acutely agitated as well. So uncooperative combative. Um So she needs to be acutely um stabilized here. Ok. That's what this scenario is getting at. Um So what when we think about how to um acutely sort of stabilize someone presenting in acute mania? Um haloperidol is, are gonna be our first choice here. Ok. So haloperidol is a antipsychotic, which we'll talk about in a bit more detail later on, but it has a very quick onset and it's the preferred initial treatment in uh in an agitated patient with mania. Ok. It's not, you don't tend to go for things like uh Benzodiazepines if it's mania. Ok. In other patients, obviously, if they're very agitated and things uh acutely delirious, you tend to go for Benzodiazepines. But in um acute mania haloperidol is your choice um for um for calming patients down. Um, other options are lithium, er, lithium is uh when people think about bipolar disorder and mania, they often just think lithium as a treatment of choice. Ok. Remember if this is an acute manic episode where you need to er, calm them down very quickly. So, Haloperidol is the correct answer here. Lithium takes too long to act. Ok. It's very long, er, it takes very long to exert its effect. That's why it's a mood stabilizer. OK. So it takes a long time for it to exert its effects. So it's not the most appropriate um option here. Um So antidepressant is definitely not the right option. OK? You um in patients with bipolar disorder mania you need to stop any SSRI s that they're on. Ok? Because they, they can worsen um worsen things for patients. So sertraline is definitely the wrong option. Sodium valproate is uh can, can be used as a mood stabilizer as well. It doesn't act as quickly as haloperidol and cloZAPine is tend to be, tends to be reserved for psychosis uh especially related to um schizophrenia. OK. And we'll talk about cloZAPine later on. So that's so haloperidol is the correct option. So let's talk about bipolar affective disorder. Ok. So, er, this is another type of mood disorder. Um, there's different types. Ok, we have bipolar, one, bipolar two and cyclothymia. Ok. The key thing to recognize here is the differences between hypomania and mania. So these are all relating to symptoms um that relate mood symptoms, that patients can have. The key difference to think about initially is the timeline. So with hypomania, it's four days or more of symptoms, you need for a diagnosis of hypomania. For mania, you need symptoms for longer than a week. But the most important difference is the functional impairment. Ok. Hypomania is just referring to symptoms being not as severe as true mania and true mania. You have true mania when you have very significant um functional um impairment. Ok. So in that scenario that in that question, I just have significant functional impairment, they're spending all their savings and they're not, they're not sleeping for four days. Ok? They're painting their rooms. That's all signs of functional impairment. Ok? Uh all these symptoms there. So increased mood, increased energy, overspending, distractibility, decreased sleep, increased libido, these can be present in both. But the key thing that you can get in mania is psychosis. Ok? So things like delusions, um grandiose per delusions are grandiose where they feel like they're like a superhero. They feel very big about themselves persecutory. They feel like someone's coming after them. Um and when you do your mental status examination on patients, uh they can have this classic finding of flight of ideas. So they're speaking very, very fast. Their thoughts are very quickly transitioning when you speak to them and their conversation flows really, really quickly and it feels like they have very pressured speech. Ok. So it feels like they have a lot to say and it's coming out very, very quickly. OK? That's what it feels like when you're talking to a manic patient and uh you can have mania with psychosis. So they can also have um auditory um hallucinations as well. Um in terms of the diagnosing the different types. So bipolar one is um essentially you have mania with depression, ok? In terms of diagnosis, you only need one episode of mania to be classified as having bipolar one. OK. So bipolar one, it's referring to patients having both episodes of mania and depression. Uh bipolar two is they don't, their mania doesn't go quite as high as true mania. OK. They're just having hypomania episodes um which isn't quite and some episodes of low mood as well. OK. But bipolar one, you only need one episode of true mania to be classified as having a bipolar type one disorder. OK. Cycloderm is when you're cycling from high mood to low mood very consistently as well. So, like I said here, so bipolar is at least two episodes of mania and or, or if you have more than one, if you have an episode of mania and one episode of depression, that's all you need for the diagnosis of bipolar disorder. Ok. So, er, drug management of bipolar is a bit of a complex area. Ok. So for the acute manic episode, like we had in that question, uh the key steps is to stop any routine antidepressants that patients are on. Ok. So if they're on an SSRI you need to stop that. Um, antipsychotic therapy. So, haloperidol is generally first line for um um calming patients down in acute mania and you can add in a second antipsychotic as well, but usually Haloperidol should be enough and then look, er, you can after that, um, start thinking about mood stabilizer. So long term, um, first line, long term mood stabilized, lithium, um for the depressive episodes, there's no, remember you don't, you're not gonna start things like SSRI S. Ok. There's no evidence for starting routine um, antidepressants in bipolar disorder. Um, it's cos and things like SSRI S have been shown to worsen things. Ok. So there's no evidence of routine antidepressants. You can try antipsychotics or other mood stabilizers to try and improve their depressive symptoms. Ok. But you're not gonna start SSRI S um, as long as it, as well as the drug management, always think about the psychological social stuff as well. So, psychoeducation CBT housing and carers as well, all very, very important in any psychiatric condition as well. Um, in terms of lithium, er, this is a very important, um, psychiatric drug. Again, I've tried to list all the important points related to lithium in this um table. Um, so just try and learn all of these um, important things. It's important for your finals as well as your PSA exam if anyone has that, um, soon as well. So lithium important side effects. So it can cause a sort of diabetes insipidus, you can get polydipsia polyuria with it. Um So, er if it's in high levels as well, it can tend to cause a tremor as well. Um lithium er affects the thyroid gland. So T FT S are important part of monitoring and it can cause hypothyroidism. Uh it tends to be contraindicated in patients who have very severe renal failure. So um uh avoid it in very severe um CD if they have ati um remember the mo monitoring is a very common question. Um So, er, before you do start someone on lithium therapy, they need to have your thyroid function tests, um pregnancy tests if they're, if they're a woman of childbearing age and ECG done as well. Um And remember, lithium tends to be teratogenic in pregnancy as well in terms of monitoring. Uh lithium levels are generally checked 12 hours um after the dose and then um regularly checked after that as well. Uh lithium toxicity as well is a very common er exam question. So, lithium toxicity, um key common triggers for toxicity is if they get very dehydrated and lithium levels start to build up very quickly inside the blood. There are some common drug triggers as well like ace inhibitors, nsaids and diuretics. Uh these can all uh trigger toxicity as well. Ok. So you can remember it with the three Ds and then you can remember the common clinical features of lithium toxicity with the pneumonic um toxic. So t for tremor, so they get a very coarse tremor with lithium toxicity, renal failure, ataxia, increased reflexes. Ok. So they get hyperreflexia and seizures as well. So, convulsions as well. Uh in terms of, I mean lithium toxicity, obviously, the don't forget the main most important step of management is to stop the causative drug. Ok. In any toxicity question, remember, the most important thing is to stop the causative agent. So stop the lithium er re rehydration because de dehydration is also a very important trigger. And uh hemodialysis should be considered very early on in lithium to toxicity. Ok. Uh Next question we're gonna be starting to talk about personality disorders. Uh Someone's asked, can you give another antipsychotic apart from haloperidol? So yeah, like I said, you can add in another antipsychotic uh with haloperidol in acute uh mania. Uh can you explain bipolar one and two again? So bipolar one. Remember it is mania and depression to diagnose it. Uh You either need two episodes of mania or uh one at least at least one episode of mania and depression bipolar two is just hypomania and um they can, their mood, it can, it can go, they can have low mood episodes with it as well. But essentially their mood is not going to into true mania. Ok. They're just having hypomania episodes. Uh is ct one for a course of treatments. Um not, not too sure from what I know it's generally a one off but patients can come in for a repeated course of CT and therapy. II think it's patient, patient uh dependent. Ok. Let's call it there. And so personality disorders is a very interesting topic. Um So both of you have chosen C here schizoid and that is the um correct, correct question. So, er, correct answer. Sorry. So, uh we got a question. Uh We got a middle aged man, 41 year old male, single, living alone. Um I've told you he's indifferent to praise, criticism, appears very distant, prefers his own company. I've told you this isn't a mood disorder, ok? He's not depressed and there's been little changes since his um, adolescence. Ok. Key thing with personality disorders is that you don't tend to diagnose them in patients under 18. Ok. These uh personality disorders are something that's generally usually developed from adolescents. Ok. And it's persisting throughout their adulthood. Ok. So this is, uh, I've tried to tell you this is a true personality disorder. I'll talk about, we're gonna go into detail of each one, in a bit. But this is sc schizoid personality disorder, which is classified by a, um, stable and pervasive traits of social isolation and indifference to opinion of others. Ok. We'll go into detail and I, I've got loads of, er, popular culture, er, examples to try and illustrate what, what each personality disorder traits are trying to describe. Um, so let's go into um, personality disorders. I got another question before we go into it. Um Have a go OK, let's call it that. Cool ma majority have got, got this question, right? So most of you have gone for c and that is the um correct answer. So, um this uh we're describing another personality disorder of all the personality disorders we talk about. This is probably the most important one for you guys uh to know about. So this is uh describing a patient with likely um uh BPD OK. Borderline Personality disorder often uh in ICU 10, they call this disorder uh emotionally unstable personality disorder. Um So we got a young woman who's presenting with uh essentially history of um self harm, multiple episodes of um self harm. Um and also very clear relationship problems. So it's a very intense relationship. Um She's clearly having very intense emotions, um clear mood mood swings happening. She's broken up 20 times self self harm episodes, uh not no actual intention to end her life, but it's because she's um having these very intense emotions, she feels alone and empty and uh she's having absence of aggression as well. So, ok, so these are very classical um personality traits in patients with a borderline personality disorder. Ok. These intense emotions, history of self harm, mood swings, physical agg aggression, um age group as well. And I've told you that there's other things like um on mental state exam, she appears well dressed calm. So there's unlikely to be a mood disorder or a psychotic disorder. Ok. Normal speech pattern thought process and thought content. So it's unlikely to be a mood disorder psychotic disorder. It's sounding more like a personality disorder and in terms of the answers. So in er, finals exams, especially the UK MLA, I found that they do tend to do more two step questions. So rather than just ask for a diagnosis straight away, they tend to make you try and diagnose the question and then come up with what the most appropriate treatment is and that's what I'm trying to get you to do here. So the question is basically asking what is the most first line therapy for borderline personality disorder in an adult? And that is uh D BT. OK. So dialectical based therapy and this is the one with the most evidence based, especially in young woman with evidence of um self harm. Um So D BT is essentially, it's a type of cognitive behavioral therapy therapy. CBT. Um and it's the one that's been shown to have the most evidence for BPD. It's essentially, it's where they have uh group skills that tends to focus on patients um um and emotions and reasons for self harm and trying to come up with strategies to um deal with their intense uh emotions. Ok. So let's talk about uh personality disorders, uh personality disorders, uh can be a bit of a tricky topic for people to understand. So with personality, remember, personality refers to someone's sort of enduring patterns of behavior. It relates to the deeply ingrained attitude, how we respond to stress and it's what typically presents from your adolescence and it persists into your adulthood. Ok. It's, that's the, w that's how we, our personality is how we deal with our environment, right? Um, it sort of defines our interests, how we interact with others and it's sort of ir related to many combination of genetic and environmental um, factors as well with a personality disorder. It's very, very important to not just label someone as having a personality disorder. Ok. Um, can anyone tell me what is the things that sort of define someone as having a actual disorder with their personality? What are the actual things that we think about? If someone, if you're gonna label someone as having a personality disorder, what's the main clinical features? You wo, you worry about that thing, that personality is becoming a problem, negative effects on their lives. Yep. So, er, self harm. Yeah. So essentially the key, the key idea is that, um, there's very, there's functional impairment. Ok. There's, the, their personality is having a problem on their daily lives. It's affecting themselves, it's affecting their, you know, relationships, it's affecting other people. Ok. So just, just la someone as personality disorder, just because, uh, for the sake of it is inappropriate. Ok. Personality disorder is when patients are having very significant functional impairment, it's affecting themselves significantly. It's affecting other people, affecting their relationships. It's pervasive. Ok. So it's very persistent. Er, they don't tend to recognize it. Ok. They don't have insight into it. Those are the things that define someone as having an actual disorder with a personality. Ok. It remember it's, it's, it can be labeled very pejorative to just say someone has a personality disorder. Ok. It's very inappropriate. It can, it's personality disorders are associated with increased risk of mental health conditions, increased risk of um suicide. So it's very, very important to be very careful and accurate with labeling someone with having a personality disorder. Ok. So when you think about personality disorders, um they tend to classify into these three different clusters. So cluster A cluster B, cluster C, uh clinically, you don't tend to really think about these kind of clusters. But for your exams, it can be useful to try and think of them uh in this way. So your cluster a personality disorders, I tend to think of them as these odd or eccentric, uh, personality disorder traits. Ok. Um, so these include paranoid schizoid and schizotypal cluster B, they tend to have the more dramatic or emotional personality traits. Ok. And this includes, er, BPD, emotionally unstable or borderline personality dissocial histrionic, um, narcissistic personality disorders. And your cluster C is your, er, dependent, er, avoidance and, er, anancastic also known as, um, obsessional um, personality disorder. Ok. Uh, there's very various different management options. Um, talking therapies gen tend to be the main thing you tend to, you go for with personality disorder management. Ok. Uh cus to B is the ones that tends to be more associated with um self harm. OK. Things like BPD. So, uh we're gonna talk about each one individually and to try and um hit the head on the point of what each of these personality disorder traits are referring to. I've, I'm gonna give you loads of, er, examples from popular culture. So, your schizoid personality type is the York patients who are disinterested in others. They're very, very cold emotionally. They don't tend to make uh attachments with people, they prefer to be alone. Um, so I've tried to pick out some characters, you know, from um personal, from popular culture, so some popular characters, uh obviously I'm not, uh please remember, I'm not labeling these characters as having personality disorders. I'm not trying to ruin your childhood or anything. I just want you to try and when you think of these personality disorder traits. It's useful to try and associate them with a, I find it useful to associate them with a character cos it might just help you remember them easier for your exam. So, things like Dexter, er, from the TV. Show Squid Wood obviously very distant are lacking emotional um, attachments. Um, the guy from Winnie, the pooh, um, Elliot Matt, um, the guy from Mr Robot, um, social network guy, these are all characters who appear very, er, emotionally distant, er, prefer to be alone, uh, disinterested in relationships. So these are your sort of schizoid personality traits? Ok. Paranoid personality trait. So obviously it's under the name, it tends to be these patients who are very mistrusting of others, they're very suspicious of other people. They're very hypervigilant. Um, so some characters I thought about, uh, your is Billy Butcher from the boys, uh, House MD. Um, um, Gollum Lord of the, er, these other characters Rick grimes from walking dead. Um, so if you can try and remember these personality traits and these are your, er, very, er, um, hypervigilance. So they, so they're very constantly thinking about other people, things that are gonna affect them. They see your pa paranoid, um, personality disorder, schizotypal. So this is where patients are exhibiting very eccentric patterns of thinking or eccentric behaviors. Ok. Or unusual behaviors or patterns of thought and their thought process is often having very difficult, um, it's causing them to have difficulty with relationships. Ok. So things like, and Doc Brown from, um, back to the future, er, Donkey from Shrek Willy Wonka, er, Luna from Harry Potter. These characters who have very eccentric patterns of thinking, you can try and think they have like these schizotypal type of traits. Ok. It's cool. Uh, borderline personality disorder, emotionally unstable. The one we talked about on that question. So, uh, this is the most important one to think about. Um, they have very unstable relationships, ok. Intense relationships, um unstable emotions, uh very significant mood swings, ok. And very impulsive behavior. Ok. So they are very prone and commonly exhibit self harming behaviors. And I said that the main sort of management option is dialectical behavioral therapy. But other therapies includes M BT and uh cat as well. So common examples from popular culture have included here like Hulk, you know, has obviously the epitome of a character having mood swings, er, wreck it. Ralph, um Harley Quinn Darth Vader, er, the girl from gone Girl. Ok. These characters are very similar to have very similar traits to patients who have um emotionally unstable personality disorder. Ok. Excellent. So, histrionic personality disorder. So this is uh your er, very, again, very eccentric. They have a very dramatic um personality so often described as being very attention seeking theatrical and their behavior is considered inappropriate or they have very exaggerated um expressions. Ok. Uh I found this one a bit harder to come up with examples for but you know, you can think of um Rachel from friends, um drink it from Hunger Games. Uh the guy from Harry Potter, the fraud teacher or Regina from mean girls, these very histrionic personality traits. So you can try and think of these um characters to help remember this uh condition uh dissocial. This is probably the easiest one to remember. So obviously, when you think about a dissocial personality disorder is patients engaging in very unlawful behavior. They have absolutely no empathy for other people. They're disregarding other people very deceitful and they try and manipulate other people for their personal gain. So you just with these personality disorders, you can just think of a traditional villain, ok, like joker scar from Lion King, um Megan from uh walking dead maleficent. You know, these very obviously exhibiting these villain traits. They're just having these an these antisocial dis social um personality traits, ok. Narcissistic. Er, so these are characters who have a grandiose sense of self importance. They have an excessive need for admiration. Again, they lack empathy for other people and try and use other people's um for their own. Um So for their own purpose. So uh narcissistic personality traits, you can think of characters like Tony Stark from Iron Man, Sherlock Holmes House MD er the villain from um Toy story three Walter from um breaking bad and these, they have these uh sort of narcissistic personality traits, ok. Uh I think we have two more so dependent personality is these uh patients who have this excessive need to be taken care of. Ok. So they're very dependent. Uh, they often have very, they often constantly need to be in a relationship or have people around, surrounding them to try and um help with their personality. So they're very submissive. They're very clingy and they have a fear of um, uh abandonment basically. Ok. This is your dependent um personality disorder. Um So I've thought about, in terms of examples, I thought about Ron Weasley from Harry Potter. You know, he constantly used to be with Harry and Ron all the time. Um Melas from um um Simpsons, um the guy from er, Lord of the Rings, er, if anyone watches Polly, you might know Ronnie from um Queen. Um These are sort of characters are a constantly need to be um be around people. They have these sort of dependent personality traits, uh two more things. So avoiding personality disorder. So these obviously it's in the name, they avoid social contact, they have feelings of inadequacy, they fear criticism or rejection from people and they have a strong desire to ha for acceptance from people. Ok. Uh This is probably, I found this one quite hard to find examples of, I thought of um Coraline from uh the movie Coraline. Um Sadness from Inside out Elsa, they avoid social contact completely. They often feel inadequate uh fear criticism from people. Uh So that's a voiding personality trait. And last one here. So your obsessional trait is, obviously it's in the name. They are very obsessive. They want, they are perfectionists. They want to be very orderly in what they do. They're, they have very rigid patterns of thinking and they're very stubborn in what they do. Ok. Um, common examples. So we got, um, er, the guy from Big Bang, um, the guy from Big Bang theory, um spongebob, er, obviously very professional, very, a bit of a perfectionist. Um, um Sherlock Holmes Joe Goldberg from you. If anyone watches that TV, show, er, key thing is II wanted to emphasize here is that, er, with personality traits, er, a lot of these traits can be useful. Ok. So a lot of people will say that having obsessional traits can be useful. Like if you think about a surgeon, a lot of patients, patients might be happy if their surgeon is very obsessive, you know, they're very, er, they wanna be very perfect and they're very detail oriented but it can also, but with personality disorders it means that it's significantly causing functional impairment. Ok. So if you think about the surgeon, you can say because they're so obsessive, they're just not able to, actually, they're so scared about actually like putting a needle through or cutting a little bit of tissue, they're just not able to do anything because of their obsessive traits. Ok. That's what you need to think. About, ok, these traits can be both useful and um harmful to patients. Ok. It's on a personality disorders is on a spectrum. But you need to be thinking about how is this disorder causing a functional impairment in patients? Ok. So hopefully that sort of hit home the, the point of personality disorders and hopefully those popular culture characters were useful and you can try and associate them. I've got a little quiz for you guys to try and um test your knowledge of personality disorders. So we got a little vignette. So we got a 27 year old woman who requests sleep medication due to difficulty sleeping with a, er, difficulty sleeping since the break up like a month ago. She worries about handling life without er, exboyfriend support, cancel a job interview and avoids socializing despite having boyfriends, she struggles with low self confidence, fear of rejection and abandonment appears anxious but brightens easily. What is the likely diagnosis? What kind of personality disorder am I describing here? If you guys let me know on the chats? Yes, this is very clear dependent personality disorder. Ok. You young woman who's clearly very struggling with not being uh in relationships. Ok. She's very dependent on having relationships and uh uh has a very clear separation anxiety. Ok. Next one got a 60 year old man, er, brought in after a fall, er, seen by NF one, demands to speak to a consultant who he knows is currently on a trauma call, res resuscitating a patient after a car crash insists he deserves better treatment due to his contributions as a, uh, medical, um, salesman, er, his wife embarrassed mentions his frequent disruptive behavior. What kind of personality traits am I describing here? Er, histrionic? Er, not quite histrionic I II, do see why it is a little bit dramatic, but the key thing that we can get here is the narcissistic personality traits. Ok. So a lot of you said narcissistic. Yeah. So he's, he, he's having these sort of grandiose, sort of, he's assigning this self I importance to him, er, which is this classically seen in these narcissistic, uh, personality traits? Ok. Uh, we got two more 22 year old college students is described as talkative and dominating conversations by her friends. She enjoys being sent for attention, often wears short skirts in lectures. Um, after a minor injury while clubbing, she fabricates a story to her friends claiming she was attacked and had to go to hospital for treatment. Yeah. Well done. So this is more of your histrionic. Ok. This is clearly she trying to describe more of a picture of someone who's trying to seek attention a bit more. I've told you she likes being sent her attention tries, uh, being a bit, it's a bit more dramatic. She's had this story of clubbing and she's tried to make it a bit more dramatic saying she's got, she needs to go to the hospital. Um So this is histrionic and personality traits. Uh, lastly, er, last one here. So 8, 18 year old woman declined an invitation to a close friend's birthday party. Er, she's highly reserved and isolated with minimal social connections. Constantly fears, criticism from others, overly sensitive to any form of rejection and exhibits a strong attachment to her mother, avoidant personality disorder. We all done. Ok. So it's clear she doesn't, um doesn't engage in um um in uh so um social relationships and because of that, they often get a attached to their close family member. OK. So I've told you they get attached to, she's attached to her mother, she's pe from the others. So she doesn't get into these relationships because she's fearing criticism from others. OK? And that's classic for avoidant personality disorder. OK. Slightly different from schizoid where they just like the being in their own company and avoidant. They, they fear criticism from others and that's what's causing her to be. Um uh um not have to not have relationships. OK. Uh She's 18 though. Isn't that too young? So yeah, so you don't tend to diagnose personality disorders in under 18. She's 18. So you can technically diagnose it. Um But yeah, ideally you are you on a bit more um history to diagnose and personality disorders. But she's 18 though. You can diagnose personality disorders at 18. But yeah, personality can be, tend to be, can be changed up to up into your twenties or so. And so you don't tend to diagnose personality disorders in young people. Um Generally. Ok, cool. So as your personality disorders, II have a feedback form at the end, specifically relating to the use of the popular culture characters, I'd really appreciate if you guys can just um fill, fill that one out um when you get the form. Um but yeah, let's move on to some other conditions. OK? Ok. Let's call it that. OK? A bit of a split. Uh Most of you have got gone for B and so some of you have gone for E as well. And the correct answer here is uh B um So uh this is a clear picture of a psychotic disorder. OK. We're sort of painting a picture of er, schizophrenia. Er, so you got a young man and basically, um we describing a picture of these, er, delusions. So his mother found him locked in his room talking about government conspiracy. He said he's never done this before. Er, he was suspended last month um for not attending classes, he's becoming more socially withdrawn and a, he's a cannabis user and um no friends or social contacts, er, family history of schizophrenia as well and on examination and he appears unca disorganized and as positive of speech is classic for schizophrenia patients. So questions has, er, gone on a bit, it's a bit of a harder question. It's not just asking for a diagnosis. I'm trying to get uh get you to think which is the most um which of these option is gonna ha uh the best prognostic factor. So in terms of nice guidelines, mice actually have er, highlighted what factors are associated with a poor prognosis in schizophrenia and I've listed them out here. So all these other ones are basically associated with a poor prognosis in schizophrenia. Ok. So being younger, they're using cannabis and alcohol, uh male sex as well and predominance of negative symptoms. So, in terms of schizophrenia, when you think about negative symptoms, you know, flat affect social withdrawal, that's all been shown here. So in case, so you suspended last month, you're becoming more socially withdrawn. Um Those are your negative symptoms and that tends to be uh highlight a worse prognosis in, in schizophrenia if they predominate, um acute onset of symptoms is uh generally associated with a more favorable prognosis. Ok. So I told you your symptoms already sort of started within and a few months. Ok. So it's, it's not like a insidious onset. So nice guidelines. I've highlighted that an insidious onset of schizophrenia tends to be, have a worse prognosis. Ok. So that's why the acute onset of symptoms in this case are, are more um likely um a better prognostic factor for this patient. Ok. But all of these other ones are w are worse prognostic factors. Uh Another questionnaire, this one's a bit more pharmacology related. OK. I think most of you are. Got this, I'll call it that. So. Um yeah, most of you have chose, chosen option C and that is the correct answer. Can you guys tell me what is the um complication that this patient has likely developed? What uh uh before I go into the answer, yes, acute acute dystonia, er, there's not, not quite oy crisis. Um, even though acute oculogyric crisis is part of acute dystonia. But in this question, Stan I've told you that this patient is having this sustained contraction of the neck to the right side and that's acute dystonia. Ok. If the, if the eyes started rolling back and just a fixed um pointing deviated upwards, that's uh ocular gyro crisis, which is a, which is obviously part of acute dystonia. But yeah, this is pointing towards um acute dystonia and you guys are right. The most appropriate management option is uh procyclidine. Ok. Um What kind of drug is procyclidine? How does it act? How does procyclin not work? Classification of drugs as procyclin? Yeah, antimuscarinic good. So generally for your um acute dystonia, which is a extrapyramidal pyramidal complication of antipsychotic therapy, it tends to respond well to anticholinergics. Ok. Um So acute dystonia um tends to be quite quick onset. Ok, develops within hours to days of starting antipsychotic therapy, especially if it's a um a typical antipsychotic like haloperidol which um unlike your atypical antipsychotics to haloperidol is more associated with extrapyramidal side effects. And, yeah. So acute dystonia is characterized by muscle spasms. So that's what's being described here and it's managed with procyclidine first line. So, schizophrenia, I'm not gonna go too much detail of this. Er you um in terms of schizophrenia, er very common psychotic disorder for your diagnosis. Remember your child? Um, first rank um symptoms. So your delusional um perceptions and third person auditory hallucinations, which is usually a running commentary type of hallucination and some kind of thought disorder. OK. It's either insertion, broadcasting removal, some kind of thought disorder and passivity phenomenon where they feel they're being controlled by some kind of external force. OK. Um Someone does what is a delusional perception? So basically a delusional perception is where um they basically having a delusion in response to a perception. OK. Um So for example, they might say something like uh that traffic light turned red. So that means I am I'm the chosen one or something like that. OK. So it's a de it's a delusion in response to a real life stimulus if that makes sense and you've got your other symptoms here. So you have positive negative cognitive and motor symptoms and in terms of your management. So uh psychological therapies like psychoeducation, CBT family intervention therapy, art therapy are your first line psychological therapies. Um Art therapy is often not talked about in med school, but art therapy is really useful, especially if they predominantly suffer from negative symptoms. Um art therapy has been shown to improve their sympt negative symptoms. Like, so things like music, drama, arts and things that have been shown to improve their negative symptoms and in terms of your drug management, so you're gonna, we'll talk, I got a slide on antipsychotics next. But your choice of antipsychotic first line is gonna be your atypical antipsychotic. Ok. Um So things like OLANZapine risperiDONE, um if they don't respond after 4 to 6 weeks, you'll try, try a different one. And your treatment resistant schizophrenia is when you're gonna try cloZAPine. Um if they're not compliant with antipsychotic therapy. Um so things like if they're struggling with tablets and things you can consider an an a long acting de depo injection, especially with risperiDONE and there's loads of monitoring you need to do generally for antipsychotics. CloZAPine is a, is a very commonly tested drug in final. Ok. You need to know there's loads of side effects which I've got highlighted on the next slide. It requires very strict white blood cell count monitoring, uh generally weekly for 18 weeks, then fortnightly up to one year and then monthly. Ok. Because of the what is the major complication of cloZAPine that you need to, that needs strict white blood cell count monitoring. Yes, a ac cytosis very very can be, can be dangerous. So, cloZAPine can um shut shut down your bone marrow can stop uh a blood, a blood cell production. Um which is obviously gonna increase your risk of very dangerous infections and sepsis. So it needs very strict white white cell monitoring. Ok. Um Someone's asking for the feedback for me, uh happy for the feedback form to be sent out if you want. Um so antipsychotic therapy. So this slide is basically a summary of antipsychotics. Um I'm not gonna go into too much detail of this. So you can have a read of it. But remember you with antipsychotics, you have your typical and atypical antipsychotics, typical antipsychotics have higher risk of extrapyramidal side effects as well as high prolactin. You know, just because of how they interact with dopamine pathways in the brain. Do typical antipsychotics um suppress dopamine production more in a particular pathway which is gonna increase your prolactin. Ok? Because dopamine normally inhibits prolactin release multiple side effects to be aware of. Ok. With antipsychotics er because it has multiple um it it affects multiple different pathways. So have a read of these different things. Uh typical antipsychotic has more risk of extrapyramidal side effects. Atypical antipsychotics has a high risk of metabolic side effects and antimuscarinic effects. Ok. Uh So things like weight gain and antimuscarinic effects like um blurred vision urinary retention more common with your atypicals. Ok. And your extrapyramidal side effects uh which are more associated with your typicals. Uh you can use the pneumonic adapt to remember it. So it's acute dystonia, akathisia, parkinsonism and cardiff um dyskinesia. Ok. Uh have a read of these uh different symptoms of each and how you manage them. Uh, rheumatology of dyskinesia is your sort of, um, the one you really don't wanna have. Ok. It's often irreversible. If people get it, they get, um, lip smacking and things and there's no real effective treatment for it. Ok. So, tardive dyskinesia is probably the, the worst one you really don't wanna have if you're on antipsychotics and it's important to be counseling patients about the potential risk and be because often actually happens after several years of antipsychotic therapy. So that's a really dangerous one. Uh Let's move on. Uh Ellie, could you paste the um personality disorder form as well? Um That I posted earlier, I'll put it. Uh I just pasted a li a Google form link for the personality, personality disorders teaching uh ju just for just to see how we did that. We just uh we appreciate you guys can just fill that out and see if that that was useful for you guys or not. Uh So if you just take uh time at the end of the session just to fill that out, I'd really appreciate that. Um Yeah, so let's call, call it that. Yeah, most of you, most of you are very, very confident in this question. The correct answer here is ad uh so quickly touching on uh postpartum psychiatry. Um So we got a young pregnant woman, had a three week old baby basically having this episode of postpartum psychosis there. So she's had this um episode of um um er with her infant where she felt the infant was possessed and er, er, nearly drowned, drowned the baby as well. Um She's openly responding to ordinary elution. So this is clear, um postpartum psychosis uh questions more um asking about the sort of what's the um law, legal aspects here. So what's the best thing to do with this patient? So this patient uh nearly basically killed this um child and is having acutely psychotic episode. She clearly lacks um capacity here. And um the most appropriate option here is to emerg to admit her to hospital specifically. The she needs to be admitted to a mother and baby unit. Um be because of the psychotic episode to have a inpatient um treatment. Ok. She doesn't have capacity. She, she's not gonna, she can't um come in for um under treatment, voluntary treatment. Ok. She needs to be at um detention in a hospital through a section through the Mental Health Act. OK. Uh treatment at home not appropriate here. She needs to be admitted. Uh urgent referral to social work or perinatal is not quick enough. Ok. As the patient is a, is a high risk of uh in infanticide uh needs to be detained er acutely. OK. Transfer to heart police and charged with 10 murder is not the most appropriate. Initially, she needs to be uh she needs to have treatment in the mother, mother and baby unit here. Ok. Um Cool. So paranasal conditions. Um uh so briefly. So, postpartum blues, this is your normal postpartum um, symptoms. So your reduced mood symptoms, uh generally very quick after delivery, you usually results within 10 days. Those are your general postpartum blues. There's no functional impairment and it's just supportive therapy for these patients. Ok. Very, very common symptom after pregnancy. Ok. A lot of, a lot of mothers will feel like this. But your actual postpartum depression is when it's persisting over 22 weeks and they're struggling to, they often struggle to bond with their baby. They have obsessional phenomena and this is when you start considering treatment and for their depressive symptoms. Ok. So you can start things like Siasia postpartum psychosis. I as you mentioned that question when they're having these psychotic symptoms, it usually starts a couple of weeks after they've delivered and yeah, treatment. So admit to mother and baby unit, I consider use of the mental health facts or a section and other treatments as well. OK. I've listed some of the medications to be thinking about for pregnancy and which uh some of so these aren't these drugs like lamoTRIgine. So means are safe in pregnancy. These drugs are teratogenic. Ok, sodium valproate and lithium are teratogenic. Uh I thought I'd quickly uh do a little bit of explaining on the Mental Health Act. Cos a lot of students find this really confusing um and especially psychiatry law can be very confusing for people. So I try to make this flow chart to help you guys um sort of visualize er the Mental Health Act. So Mental Health Act, essentially it's a law that's in England and Wales. Um it's um used on patients who have some kind of mental health condition um and doesn't need that consent and they need to be admitted to the hospital because they're at risk of um uh significant harm to themselves or harming someone else. Ok. So that's when you need, that's when you're considering to use the um Mental Health Act. So essentially I made this flow chart to help visualize one that to you. So if a patient patient's refusing treatment, they have a mental health condition. So some kind of mood disorder, psychotic disorder, personality disorder, learning disability, any of the the these things and they require admission. Ok. So they are refusing voluntary treatments, other options considered and they are at risk of harm to themselves or someone else. And there's, you can have some kind of appropriate treatment in place in hospital. That's when you would consider using the Mental Health Act. Um there's no alternative to admission. So they can't be treated at home or something like that. And then you need to think about the specific section. So if there are, there's time for a section two or section three. So section two or section three, is basically um a section to either assess the patients in hospital or or as well as potentially provide treatment. So section two specifically for further assessment in hospitals. So if they need further assessment, then you can do a section two. If it's more, they need treatments. Uh then you can do a section three. Ok. So section two for further assessment generally lasts about a month. Uh Section three is about six months. Ok? And then if there's not, not enough time for section two or section three, then you can think about if they're an outpatient or an inpatient. Ok, if they're an inpatient, so they're uh they're, they are already um in the ward. Ok. They're already in the hospital ward and you need to keep them in hospital. Ok. So essentially you need to have exer emergency holding powers. Um So you need to hold them in hospital for a certain period of time until you need, they can have a other section like a second two or second three. Done, then you can use these sections. Ok. So section 52 is a holding power for doctors. Er, it can keep patients in the hospital for up to 72 hours until you can get a approved mental health professional or section 12 doctor to do do a more longer section. Uh Section 54 is for nurses and that can hold patients for up to six hours um or, or until a or until a doctor fills out at 52. Ok. Uh if they're in an outpatient setting, so for the, for example, the emergency department and then you can go section four to keep them in the hospital. Ok. Um Those are your, these are your sort of holding powers in emergency um treatment um treatment sections? Ok. And I made this table to try and summarize these specific timelines and what each section Mental Health Act section is referring to. Ok, so have a read of what each one is really again, really briefly. Section two and section three are for assessment and treatment. Section two is for a month. Section three is for six months and you need to have er two doctors and an approved mental health professional sign it off. Section four is your emergency treatment and in your, in your emergency department you only need one, approved, you need only need one doctor to sign it off. Uh section 5254, your holding powers. 52 lasts for 72 hours. 54 for nurses lasts for six hours. And your last ones, these are your um police uh police. Uh these are the police um section. So section 135 allows police to enter someone's ho place of home and remove them to a place of safety. Um Section 136 is allows the police to move a patient from a um from the public. Ok. So from somewhere in public to a place of safety. Ok. Um, so there's a slight difference there. Uh, 135 also needs a magistrate order as well. You need to have a search warrant. Uh, you need to have a warrant to enter someone's home er, before you can do section 135. Ok. So that's your mental health fact. Ok. Hopefully it's a little bit clear. I've got a couple of scenarios here for you guys to have a go at thinking about what mental health fact section you would use. So we got a 28 year old male. Um that uh 28 year old male was reported to police by ra staff after they prevented him from attempting to jump in front of a train sub. Subsequently, the police has quoted him to the nearest A&E for assessment, which Mental Health Act would you use here is uh has been used to just say. So they were in, they were at the train station and they've been moved to A&E what sections been used. So, so 136. Very good. Ok. So they're in a place of safety and they've been moved to A&E for further assessment. So that's the section 136. Exon 21 year old male presented with first episode of psychosis er seen by a consultant uh needs to be admitted for formal assessment. But the man is adamant that he wants to go straight home, which me Act of the Mental Health, which section of the Mental Health Act could be used here? Ok. So this would be a section two. Ok. As long as you can, uh this is assuming obviously you, you have to, you uh time to have a mental health professional and two doctors to do it. But uh uh we're assuming that that can be done and they can be uh as they can be sectioned for, for formal assessment for up to a month. Uh next 13 year old woman, er, sorry, they should say uh let's just say this. Uh 32 30 32 year old woman who is a uh an inpatient on a psychia psychiatry ward with depression had agreed to her admission one week one week ago. Now trying to leave, she has told the nurse that she's following the Dell's instructions to her and will jump off a bridge when she has left Psychiatry. Medical team are all away on a conference. What's the most appropriate thing here? And I've told you and we're thinking about a nurse here. Yes, section 54. Yeah. So 52 is for doctors, remember section 54 is for nurses. So this is uh the thing about the nurse, nurse handling the situation is so she can fill out a section 54 and hopefully within six hours she can get a doctor or some mental health professional to come in and um assess the patient to potentially extend the se section. Uh see what needs to be done. Uh Two more scenario, we've got a 58 year old man with known severe depression being managed in the community has recently deteriorated and is not currently safe at home. A community psychiatrist decides that he needs admission for treatment although it is against the patient's wishes. Yeah, it's a bit of a tricky one. So this patient is is not in the hospital. Ok? They're in the community they, that needs to be admitted urgently but you don't have enough time. So what? So a section three? Yeah. Ok. So um so I again, I I've kind of been making you assume that the they've sort of, I've tried to make it clear that they're known to a community psychiatrist so they have depression, they've recently deteriorated, they need further treatment. Ok. So section three is your one that se Mental Health Act section that allows you to have treatment um in hospital? Ok. And this is up to six months. Ok. So again, remember mental health fact is uh you don't need patient's consent for it. Ok. Even if patient doesn't consent, you can use mental Health Act. Ok. Um So section three allows treatment in hospital for up to six months. Ok? E even if it's against the patient's capacity, you can use the section three to do treatment. Uh last one, 25 year old man presents er to the emergency departments on a Saturday night having bathing strangely, his only speech is an impersonation of a rap artist while he does, er, which he does while breakdancing history of bipolar disorder. Usual consultants only available on Monday but attending doctor decides he needs to be admitted until then. And, uh, someone's asked why is the previous one? Not a, 135. So 135 is a police, um, er, power. So that's some sort of scenario like um they need just urgent assessment in the emergency department. They need emergency assessment by a psychiatrist in hospital or some somewhere. And that's and and they're in a high risk setting. So the police need to escort them to hospital. That's when you think about section 135. But here I've made, I've tried to make it clear that they need treatment and they're just not consenting to treatment. So you need to be uh so they need to have a section three. Um So yeah, last this one here is a section four. So this is a section four. So er they need, this is basically holding powers. So it's not a 52 because 52 applies for inpatients. Ok. So this I told you this patient is presented to the emergency department. So they're, they're not uh they're not on the hospital ward. So you, you, you don't have the power to do a 52 holding power. You need to do a section four which is basically like a section 52, but it's used on outpatient. OK. So they've presented to the emergency department, you do a section four, which can last up to 72 hours and then the consultant can uh assess them um within that time. OK. Hope, hope. Hopefully that that's clear. OK. Mental Health Act is a very tricky concept for students, but hopefully some of these scenarios and that um flow chart can, has tried to make things a bit more clear for you guys. Let's move on. This question will probably be a bit controversial because technically you would do all of these um steps, but er questions is asking what is the most important diagnostic um step and you, you probably won't get a question, this kind of vague in your actual medical finals, but it's just trying to emphasize a key learning point. So let's call it that. Um So yeah, we have a big split between A&E I've said the correct answer here is e uh so look at his prescription. So um we got a patient here who's basically presenting with signs and symptoms of a psychiatric emergency. OK. So they, I've told you it's a psychiatric inpatient. OK. They're probably on some psychiatry me me medication and like someone said, it does sound like neuro electric malignant syndrome. OK. So hyperten hypertension tachycardic Orex, very drowsy rigidity, rigidity is a very key cymp and Ne Malignant Syndrome. It's one of the key things to differentiate from serotonin syndrome. Um They, with neurol malignant syndrome, they get very, they get what's described as lead pipe, uh muscle pipe, uh rigidity. Um So nm is something to consider here. But question the question more, ask what is the most important diagnostic that what is the thing that can help you different between things like se and NeuroActin malignant syndrome. So, the key thing with psychiatric emergencies like serotonin syndrome, neuroactive malignant syndrome is what drug have they been given? Ok, because they have very clear, different causes. Ok. Serotonin syndrome is caused by things that increase serotonin. So things like SSRI s antidepressants uh and things N MS tends to be caused by things that affect your dopamine levels. Ok? So your antipsychotics uh typically are implicated in neuroleptic malignant syndrome. So that's why I've said the correct most important diagnostic step here is to just look at his drug prescription, what has he been taking? Um because that's the most important thing to try and figure out what the diagnosis is. Ok. Creatin kinase levels is a good thing to do and you would check it. Ok? If it's elevated, it would tell you. But creatin kinase is elevated in both serotonin syndrome and in neuroactive malignant syndrome. Ok? It does tend to be a bit higher in neuroactive malignant syndrome. But that's why if you know the actual drug that they've been taking, taking or they've been put on, that's gonna help you identify the cause better. Ok. So uh it's a quick summary of psychiatric emergencies. So, serotonin syndrome and new elective malignant syndrome. Ok. Um not gonna go too much into the differences. Ok. Serotonin syndrome is a bit more acute. It's caused by serotonin serotonergic agents like SSRI sn neuroactive malignant syndromes caused by antipsychotics or if you suddenly stop taking um dop dopamine drugs like antipsychotics as well. Uh symptoms can be very, they can be very similar. Ok. Um but I've tried to highlight some of the key differences. So for example, the rigidity in your electro malignant syndrome, whereas you tend to get more clonus in serotonin syndrome and in terms of the management. Ok. Um obviously, the most important management, like I've said before these emergencies is stop the causative drug. Ok. So, Serotonin syndrome, stop any antidepressants, neuroleptic malignant syndrome, stop antipsychotics, er supportive care fluids as appropriate and neuroleptic malignant syndrome. Um Second line agents you can use like Dantrolene, bromocriptine or Dantrolene is a muscle relaxant. Uh bromocriptine is a um B blocks dopamine. Ok. So um sorry, it increases do uh dopamine agonists, so it increases dopamine levels. Um So these can be used in severe cases of N MS. Serotonin syndrome generally tends to be very supportive. Ok. Ju just um supporting a patient cooling as appropriate and fluids and end stage cases, you severe cases, you can use things like cyproheptadine as well. Uh We got uh I think four more questions. So a couple more conditions to talk through uh should um hopefully get through them quite quickly. That's why is higher in N MS. Um I'm not too sure about that. It's probably, it's like it's likely related to the pathophysiology. In new like malignant syndrome patients are at risk of uh rhabdomyolysis, much more higher risk compared to serotonin syndrome. So, myolysis does uh significantly increase creatin kinase levels. Uh which could be a reason why. Uh but generally, uh CK levels will always, almost always be elevated in N MS. They, they, they might be normal in serotonin syndrome or just slightly elevated. Ok. Ok. Uh Call it that. Um so most of you have gone for a and that is the correct answer here. So what is the diagnosis here? What is the, what do we, what do you think this uh little girl has? Yeah. A and so yeah, anorexia nervosa is we're trying to paint a picture. Anorexia nervosa. And the question is asking in addition to nutritional rehabilitation, which is obviously gonna be the most important management. Um question out what else is appropriate to treat er for treating Children, especially in terms of their psychiatric symptoms and the actual um eating disorder and thing uh uh thought processes. Um First line is generally family therapy. Ok. So we got a young child complains of feeling cold all the time, depressed for mood disturbance for two weeks. Uh despite feeling overweight, she wears extra clothing. Ok. So again, the point towards a, yeah, eating disorder, um, cycling is the only activity that warms her up. Ok. So she's, er, exercises regularly, poor concentration, uh, denies any suicidal ideations and she has classic examination findings for anorexia, nervosa. Ok. Thin with dry skin, uh, brittle hair. Ok. Calluses on the hand. Uh, anyone know what calluses on the hand might be referring to what might be, what is it, what is it called? Does anyone know the sign? Yeah. So, yeah, so it's called Russell Russell sign. So it's referring to um purging behaviors. So, uh pa er anorexia patients who might in uh undergo purging behaviors to try and reduce their weight and um induce self, induce um vomiting um that they can get classic calluses over their knuckles uh because of their teeth um and sort of grinding on that, grinding on that area. Um Other things. So she's bradycardic. Ok. Um So someone said, isn't that bulemia? So, yeah, bulemia is, you can get purging behaviors even in anorexia. Bulemia is the one you would think about more with um purging behaviors, but you can, you can get anorexia patients who purge as well. Um pulse is she's cardic uh BM I is low. That's what the key feature of anorexia obviously in, in terms of diagnostics, in terms of differentiating anorexia and bulimia. One of the main things to look at is their BMI, if their BMI is low and she's cytopenic as well. So she's got low hemoglobin, high, high, high high platelets, uh high leucocytes, thyroid function tests are normal. So question asking, what is the first line psychiatric therapy generally. So, family therapy is the first line, especially in um Children and especially in Children or adolescents. Family therapy is the first line and it tends to focus on, you know, the family as a whole and try and improve their um thought processes regarding eating as a family as if as it's the family who's gonna be supporting that child, family is gonna be cooking meals and things. So it's trying to help to see how the family can as well as a child, um can um help in that recovery process. Ok? Um Medications don't tend to be useful unless they have very severe comorbid depression. You're not gonna, you don't tend to prescribe antidepressants in anorexia. Ok. Mirtazapine um does in increase appetite and it might be a useful option to consider in some patients but not in anorexia. Nervosa specifically, it tends to be family therapy, some kind of CBT which is useful for most useful for patients. So, uh I've talked about loads of different psychotherapies throughout this session again, II think as uh students do find it odd to remember which therapies for which condition. So I've tried to make this summary table for each, for the indications of each different psychotherapy. Um So hopefully this will be useful for your Revi revision. OK. Things like PTSD. Remember um eye movement Deen and reprocessing therapy is first line eating disorders. We talk about the family therapy and things. Um So try and uh learn this. We talked about D BT before for Borderline Personality Disorder. So just try and remember which therapy is first line for which um condition. OK? Because there's loads of different types of psychotherapies which focus on different um areas of um mental health. Ok. So hopefully this table is useful for you use for you guys. I've got another question and then we'll talk about eating disorders. Uh, why not if she is depressed? So, as as I said, so antidepressants don't tend to be the first line, don't tend to be that useful in anorexia and thus they have very severe comorbid depression. Ok? I told you in that case, she wasn't having any suicidal ideations. It, it wasn't, it didn't appear to be very severe um, depression. So it, there was an indication there was no indication to start antidepressants in that patient. Uh That table wasn't in order of first line, second line. It was just which the therapies are um indicated for which condition I didn't do it by order of first line. Second line. Um Yeah, but generally generally psychotherapies and medications are go, it's you think about psych psych psychotherapies, first line before you start medications. That makes sense. Ok. Um Give me 10 more seconds, a bit of a trickier question. Yeah, let's go to that. Ok. Bit bit big split here. Um, so, um, this is basically talking about the medical complications of um anorexia. Ok. So we've got, again, young girl, um, er, has, er, has secondary amenorrhea. So, so, so the correct answer here is um, a um, fractures. So we got a um, young girl, er, who's having se secondary amenorrhea, which is again a, which is a complication of um a anorexia. OK. Er I told you she was preparing for an important competition. So it's probably likely uh uh sort of um pointing towards she's probably exercising significantly or very concerned about her bo bo bo body image. Um She has very low er BM I OK. Bradycardic uh hypotensive again, features of anorexia, um bilateral soft masses below a mandible. So it's parotid swelling again, very common feature of anorexia and skin over dorsal side of right, kind of thick. And again, I, as I said in the last question that Russell sign, which is a feature of um purging behaviors and anorexia. So again, this is uh I've tried to hold in on these two step questions. So it's not just about getting the diagnosis, try and think about uh try and think a step ahead. So questions asking medical complications of anorexia and of all these options. The correct answer here is um fractures. So if you go through the other options of hyperphosphatemia, um you in terms of electrolyte abnormalities, anorexia is, er, is a bit complex but um which er, what electrolytes er, tend to be affected in anorexia. What, what kind of pattern of electrolyte abnormalities do you tend to get? You guys? Let me know. Yeah. Hypo hypokalemia. Very. Yeah, hypokalemia. And, yeah. So especially, uh when you think about refeeding syndrome, which I'll talk about. Ok. When they, if, if, especially if they start eating meals, it tends to be your potassium, your magnesium, your um calcium, which tends to drop. Ok. So it's not, you don't tend to get high, high phosphate. You, you can get low phosphate with anorexia and you tend to get low potassium as well. Those are the main things to you worry about uh cardiac effects. So, um in terms of QT interval, um because er, you can get hypokalemia um and hypocalcemia as well, er, your QT interval tends to be prolonged. Ok. Um Some of those, what are the parotid masses? So, yeah, you tend bila bilateral parotid swelling is just one of the clinical features of anorexia. Ok. That's just er important. Uh one of the core examination findings to see in anorexic patients and recurrent infections. Um So th this is a very common misconception about anorexic patients. Ok. So, um even though their full blood count drops, ok. Even though they can, the white cell count can drop. They as, as, as soon as you, they, it's very reversible. Ok. Even if their white cell count drops. Yeah. As soon as they start um, feeding, feeding, uh you know, they, their nutrition that is completely reversible. Ok. So a, a patients with anorexia, they're, they're not, they're not at a, at a higher risk of infections compared to a, any normal healthy patient. Ok. The risk of infection is, is comparable. Ok. It's not um, fractures is a much more common complication compared to infection. Ok. And why do patients get fractures? So, because they're not eating adequate nutrients, they get osteopenia, osteoporosis, uh which er as well as they have lack, they have their estrogen levels are quite low as well. So their bone mineral density is very low. So that much higher risk of fractures. And also because a lot of these patients will be exercising a lot and putting a lot of stress on their bones, they're at a much higher risk for getting like stress fractures and things uh as well. So that's why fractures is the most correct option here. So um I'm not going to go through all this again. This is mostly for your reading. OK. About anorexia, nervosa, key diagnostic features, you know, you think about is this picture of fear of weight gain, low BM I, they're not eating properly, secondary amenorrhea and there's loads of different um medical complications because of it. Ok. Uh So have a read of these uh in terms of management, like we said, um weight restoration is key generally, you, you try to aim for a weight of about um uh half a kilo or a kilo per week. Uh But there is a risk of refeeding syndrome, which I'll talk about on the next slide if they have very severe depression with it, uh you can start uh SSRI S but only if it's severe. And in terms of psychotherapies, if they're less than 18, family therapy is first line. Um Otherwise in adults who tend to go for CBT or IBT um as well, uh low on refeeding syndrome and put a medical complication. So, when you've admitted someone like for um anorexia, nervosa, and you're gonna start treatments uh start a feeding regime for them. You need to be very careful about the risk of refeeding syndrome. So, because uh because they've been starved for so long and when you, and once they start some kind of oral intake, there's gonna be a big insulin surge. And big thing with, with insulin physiology to remember is that insulin will cause an intrasellar shift of multiple um substances. So obviously, it'll, it'll bring down um your glucose levels, but it'll also cause intracellular shifts of potassium magnesium and phosphate. Ok. Sorry, I think I said calcium before it's your magnesium that drops in um uh anorexia. So then that's why it increases the risk of uh q uh prolong of prolonging your Q QT interval. And so because insulin causes these um shifts of potassium magnesium phosphate, these electrolytes can drop in the blood and uh that's why you need to regularly monitor them. OK? Because obviously if you have these electrolyte abnormalities, they can cause serious adverse effects, especially um dangerous um arrhythmias. Ok. Um Cool. Um in terms of management. So yeah, I just have a read of the different management because of these electrolyte abnormalities, they need to be on the cardiac monitoring regularly once you start the feeding regime. Ok. Uh bulimia, a little slide on bulemia. So it's slightly different to anorexia, nervosa. Ok. It's characterized by recurrent binge episodes of binge eating with compensatory behavior. Ok. So whatever they eat, they're trying to basically uh reduce. Ok. So, um they, uh it's characterized by self induced vomiting, laxative abuse, excessive exercise, fasting diuretics. In terms of diagnosis, you tend to think about having at least two episodes of these behaviors per week for three months. Ok. And they're not having prominent weight changes, ok? They're not losing significant amounts of weight or gaining weight because whatever they're eating, they're basically just trying to get rid of that. Ok. Uh Very commonly coexists with other mental health conditions, er, clinically it's, their BMI is normal. Ok. Their weight is normal. Uh they often are very, they often have a depressed mood, low esteem and because of their eating patterns, their periods can go off the charts. Ok? They can have very irregular periods and there's multiple medical complications. Ok. Mallory wise test because um if you remember from gastro, it's called, it's, you often see this in patients in alcoholic patients who uh constantly retching and these bulemic patients, they're constantly vomiting. And that can cause um tears in the um uh lower esophagus, upper upper stomach, which can lead to man wise, tears and upper gi bleeding. Uh you can get salivary, gland hypertrophy, which can cause that swelling, which we talked about in the question, uh potassium can be affected and we talked about the Russell sign here, which is um seen here. Um tooth decay as well because uh they are a bit purging behaviors and because vomits constantly coming, coming up and decaying teeth and so their teeth can look like this and in terms of treatment. So generally you're gonna want to treat their mood symptoms. Ok. So SSRI S first line and psychotherapies like CBT I PT ask patients to keep a food diary as well and to see to monitor what they're eating. And yeah, that's bulimia nervosa. Uh we got uh a couple of questions on child psychiatry and one question on uh substance abuse and then we will be, we'll be done. I know it's been quite a heavy session. So thank you for er, sticking with me and we're gonna, we're gonna cover child psychiatry quickly and uh drug, drug, uh some uh drug, drugs of abuse and we will be done, er, will QT interval be prolonged or shortened in anorex. Um So if they've developed complications, like hypokalemia, hypomagnesemia, that would prolong your QT interval. So you tend to get prolonged, you would, if anything you get prolonged qt interval, er, which obviously can lead to like, um tosses de point to, to tosses de pointes um sudden cardiac death and things. So that's why you worry about um these electrolyte abnormalities. All right. Cool. Um Interesting. So, er, mostly you have gone for a and uh tried to be quite sneaky with the one correct answer is actually B here. Um So um we got a young child um presenting with um fea features of the c of a condition called AD HD. So, attention deficit hyperactive uh acttive disorder. So, uh can you tell me what are the three things that you look for in AD HD? What are the three things that sort of characterize um AD HD in terms of uh what do you need to think about for the diagnosis of adhd in a child? Yeah, hyperactivity, inattention and impulsivity. OK. And this child, this child has got all of these things. OK. So he's exhibited poor attention. So it's one of the key features and A DC is poor attention, difficulty listening. OK. Inattention and hyperactivity and uh he's having difficulties at home and in school. OK. So key thing for ADHD diagnosis, they, they need to be, have having difficulties in two separate settings. OK. So typically you need to be having symptoms both in the home life and school life. Ok. So for the diagnosis, um the the child and the cam S team, the child and adolescent team will tend to ask for teacher reports, ask for teacher opinions on students cos they need for the diagnosis with AD HD. You need to have um evidence of difficulties in both settings. Ok. Er, so this child is easily distracted, difficulty sitting, still struggles to follow instructions um as um challenging behavior as well, intrusive behavior, forgets chores displays moodiness and I irritability. So the gen generally for AD HD for, in terms of medications, your first line is gonna be your stimulant medications. Ok. So stimulants include mephen. Ok. And this is the medication most likely started in most patients, but I've added in this bit about the mother expresses opposition to stimulant medication and wishes to explore alternative options. Ok. So I've told you that she's doesn't want the child to be started on any stimulants and it's very important to consider parents opinions and things when you start treatment. Ok. So, um that's why this, this interruption er gone for um atomoxetine. Ok. Which is your non stimulant um, alternative. Ok. It's your first line non stimulate nonstimulant version um for ADHD treatment and it's generally preferred if there's uh preferences from family or if there's potential risk of abuse. So if there's um older patients who, there's a risk of potential abusing stimulant medication or the or there's a risk of them giving it, giving that medication to other people who um who are using it to abu abuse um stimulants. OK. That's when you would prefer, you might prefer to give uh atomoxetine. So let's talk about um child psychiatry. So, ad HD um as you said, uh three key FF features is inattention hyperactivity impulsivity. And I've listed different ways they can manifest and different scenarios to be thinking about. OK, for each of these uh in terms of the management of AD HD. So your first line, uh you're gonna try your behavioral modification. So um parent training, try and er introduce reinforcer reinforcement schemes, consistent reward, um setting um task um task setting and try and im um implement some kind of um consistency in their behavior. Um That's first line and, but it doesn't tend to be the most effective in treating the core features of AD HD. OK. Um That's why most patients will be started on medications. Uh First line medication is your stimulants like Mephen. Uh brand name is uh Ritalin and other er second line is your lis decimeter. Um be five. Finally, it is your first line big thing that parents always get worried about er, is obviously the side effects of stimulants. Um So it can cause er, headaches, insomnia, nausea, reduced appetite. But the most important thing to er counsel patients on is the potential risk of growth suppression. Ok. That's why you uh patients who start, uh, stimulants like Ritalin, they need to have their height and weight checked every six months. Ok. So very regular checks of height and weight and their BP and heart rate checked every three months as well. Um, because of these side effects, they can be very debilitating for patients. Ok. These are very significant side effects, especially if you think about a child, a young child taking them. Um, a lot of er, clinic, clinicians will advise patients to go on drug holidays. So they allow like periods of time where you don't need to take the drug, don't need to take the drug and just to help get some relief from side effects. Ok. So this is, you can have these drug holidays while um on um stimulants. Uh as you mentioned, alternatives include Atima and um and guanine which are non stimulants. Uh alternatives. Uh on the other side, we have autism spectrum disorder. So asd um er different condition but um can be comorbid with um er ad HD as well. So with autism spectrum disorder, we think about um other patterns of behavior. So impaired social interaction, impaired communication, uh ritualistic, very repetitive behavior. So these, these tend to be diagnosed very young. Ok. You tend, tends generally to be diagnosed by the age of two in most patients. So it, it gets observed as uh some form of developmental um delay in young child and um usually it's in the form of speech and language delay. So they have very delayed speech and language and that gets picked up and eventually they get some kind of autism diagnosis, some. Um but the key things that characterize this condition is impaired social interactions. So when you're speaking to them, they have very poor eye contact, they have difficulty in social situations and have no interest in, in any particular relationship because they're having difficulty with picking up social cues. Um they have very repetitive behaviors. So in young childs, you find that they throw tantrums quite regularly, they have these very regular and repetitive movements. So they're called um stereo systems. So you might find that they just clap all the time or they have a ha their, their hands clap all the time. They have their own kind of repetitive movement that, that, that just happens for them. And yeah, so these are these, these are what characterizes ASD and in terms of management, it's a multidisciplinary management. OK. You manage them uh what? It's very individualized management for autism. OK. It's behavioral therapies, um special schooling, um giving patients their own space, quiet places to organize themselves, psycho education for parents. OK. It's a very individualized management in autism. OK. And obviously manage any comorbidities. They might have like environmental delay, epilepsy, ad HD um as well. Generally there's no you don't. There's not much role for medications. OK. Unless they have challenging behaviors. So, antidepress antipsychotics that they have in very significantly challenging behavior might consider antidepressants as well. Ok. But generally it's gonna be your psychological therapies, er, for ASD. Uh, I got two more questions. Uh, this is a very, probably quite a quick tricky question. Probably the hardest question for you guys. I was very mean in this question. But have a go, you, you never know what's gonna come up in finals. Um, so have a go, uh, thi this is a hard question. Uh Don't be frightened if you get this wrong. II wouldn't expect uh I wouldn't expect like you came, you came later to have such a hard question. OK. We will call it the as big, big, big, big, big split. Uh OK. So we got a big split. Slight. Yeah, a big split between most of them. Uh Can anyone tell me what, what is the diagnosis say? What is the actual condition um getting at uh fetal alcohol syndrome? Not quite, it's not fa s um It's not, well, you wouldn't get uh what is this CDD trin rep um repeat referring to. And I think uh no, not uh this is Fragile X Syndrome. Very good. Whoever said Fragile XG Club. Excellent. So, yeah, this is um this is a scenario of um Fragile X Syndrome. So that's what the gene, the genetic finding, genetic test finding in Fragile X Syndrome is um increased trinucleotide repeats in the C GG genetic code. Uh Fragile X is. So the correct answer here is c long face and larger view today. So Fragile Like syndrome. Uh We're talking, we're talking about learning disability and in terms of learning disability, the there are mo many genetic syndromes which er leads to patients getting forms of learning disability. Fragile leg syndrome is the second most common cause of learning disability. And er, yeah, so fragile like syndrome, it's characterized by increased number of C GG trinucleotide repeats. Uh It's characterized by other features. So large ears, long, narrow face, hyper extendable fingers, mitral valve, prolapse and large um testicles as well. Um So in terms of the other options, uh anyone tell me what, what, which condition can lead to flat Fs and a protruding tongue. Anyone know any, any genetic conditions, which is characterized by this kind of appearance. Yeah, down syndrome. Very good. Ok. So Trisomy 21 ca er classically they get um uh the these features flat faces, protruding tongue, you know, epican folds and things, er thin upper lip and receding chin. Any know anyone know which condition fa s very good, very, very good good knowledge, fetal fetal alcohol syndrome. Uh the ca ca classic appearance, they also get er very flat, flattened um frum, there's space between their nose and their upper lip is usually very, very flat. Ok. Very characteristic feature of um fetal alcohol syndrome, uh frontal balding and cataracts, anyone know which condition leads to frontal balding cataracts is I'd be very impressed if anyone knows this. Er, so the myotonic dystrophy is a condition which can cause frontal bulking and cataracts. And last one almond shaped eyes and a downturned mouth. Anyone know any conditions which can lead to that kind of appearance. I'm really testing your medical genetics and knowledge here. I don't know. So, it's a condition called Prader Willi Syndrome. It's a, um, a, uh Prader Willi Syndrome. It's a type of genetic, um uh genetic imprinting syndrome. Um So basically the there's imprinting changes from the um there's a deletion in the paternal genes which and leads to genetic imprinting. Er, so almond shaped eyes down to mouth. You see in Prader Willi Syndrome, someone's asking what was DD was er myotonic dystrophy? Ok. Er, tends to myotonic dystrophy tends to present in adults. Er, but you can get myotonic dystrophy and juveniles as well. You can get myotonic dystrophy in Children. Um So, yeah, that's Fragile Leg syndrome. A very, very difficult question. Um A lot of genetics happening. This is summary side on learning difficulties. Ok. So there's many di different degrees of learning difficulty from mild to profound, obviously mild, it can often be unnoticed. Ok. It might, it might a lot, a lot of patients that in this end will be able to live independently, but on the more severe end, they'll get noticed very, at a very young age, they'll have global developmental delay and, and they'll often need support in many aspects um of their life. OK. Uh There's loads of different causes. OK. We've talked about the genetic causes. Down Syndrome is the most common cause, but fragile X is the second most common uh genetic cause. And there's many other causes. Ok. And I've classified them into genetic prenatal perinatal and postnatal causes. Ok. Cool. Last question. Uh Have a go again. This is quite a tricky question again. But uh have a go. This is just asking about substance abuse. You should hope you should be finishing before nine. So finishing in good time. I know it's a long, I know it's quite a heavy session, but uh we will push through this last question. OK. Let's go. That. So, very good. Most of you have got the right answer here and yeah, correct answer here is uh MDMA um uh also known as ecstasy. Uh So the question is basically asking you to identify what drug this patient's likely um taken. So we got a 21 year old uni uni student uh who has swallowed a, a substance that that's important. OK. So he's taking something orally. OK. It's he, he hasn't um done it through uh IV or um taking it nasally. So he swallowed some substance at a house party and he's developed disorientation, flushing, significant sweating and he's also had a seizure. Ok. Um He has a history of depression been on uh um cannabis before as well. Uh Observations show high temperature hypertension, tachycardia as well. Important. Um Also on examination, he looks flushed. Uh, he's sweating a lot. Um uh hyperreflexia, myoclonus and very confused or disorientated. And another important thing I've said here, serum sodium is low. Ok. So they have hyponatremia, significant hyponatremia and that drug screen is o positive only for T HC. So cannabis. Ok. Um Anyone tell me why is this likely ecstasy? What features er, what points it more towards ecstasy use than anything else? Mm. Yeah. So the, yeah, too bad. It's probably a, it's probably a combination of things, a lot of these things are pointing towards uh ecstasy use. So the symptoms are very classic. Ok. For a, so with MDMA ecstasy it's er, you get like increased uh euphoria, the people take it because they cause with euphoria increased um um sexual dis size of things and it can lead to uh these classic observations. So hypertension, high fever, tachycardia. Ok. This, this high fever is really, really important. Ok. They get such a high fever uh because they're so hyperthermic. Ok. They, they end up drinking loads and loads of water. Ok. So because they're so hyperthermic, they drink loads of water and that causes them to get hyponatremia as well. Ok. So because of the hypothermia, they get hyponatremia as well and they also get si DH as well, which contributes to the hyponatremia. But it's mainly because they're drinking loads and loads of water. Ok. So that's why they, they get hyponatremia and with ecstasy as well, you also get a serotonin syndrome as well. So, ecstasy increases serotonin and leads to features of serotonin syndrome. So that's what's causing the flushing diaphoresis, hyperreflexia, myoclonus and disorientation. Ok. So they're having this combination of serotonin syndrome, hypertension hyperthermia and the sodium is low. There. Most definitely ecstasy use. Ok. Um Other options. So cannabis, um it can, doesn't tend to cause hypertension and it typically you would get it, you would see it po er cannabis positive in the urine drug screen um as well. Um meth amphetamine um tend doesn't tend to cause the serotonin syndrome uh picture and it doesn't drop the sodium. Ok? You tend to, it tends to be more sort of agitation and they get more aggressive with um methamphetamines and cocaine. So I've told you they've swallowed it, ok? You don't tend to swallow cocaine. Ok? They tend to, it tends to either be they snort it uh so nasally or do it through an IV. And um yeah, so and it typically cocaine, you'd be positive on a urine drug screen as well. Uh Benzodiazepines uh it tend to cause the opposite observations. Ok. You'd get low heart rate, low BP and it would also be positive on a drug screen as well. Ok. Uh someone else, why not option C so amphetamines, um it can cause a similar picture. Ok. But you don't tend to get the Serotonin syndrome as much and it tends to be, you definitely don't get hyponatremia with the meth methamphetamines. Ok. Um, so it's mainly the hyponatremia which definitely makes it, um, ecstasy use if that makes sense. So, yeah, MDMA ecstasy is interestingly c and uh methamphetamine, they can take a lot, a lot, a lot longer to show up on a urine drug screen. Ok. That's uh, another learning point here. So ecstasy doesn't necessarily show up on the urine drug screen. Cool. That was the last question. So I've got this uh summary table on drugs of abuse. I'm not gonna go through this. OK. This is just for your revision. Um But in terms of abusive drugs, you can classify them into stimulants, hallucinogens, opiates and depressant drugs. I've listed some of the key things to think about for your finals exam and what uh key things to look out for out for in the question. Uh Yeah, we talked about ecstasy here and just have a read of the key things in terms of side effects and withdrawal effects. OK? So what happens if someone suddenly stops um taking the drug? And yeah, that's it. So I've got some postelection notes for you guys as well. So once you get the slides, I'll send I upload the slides er later tonight and uh you there's I got some notes on anxiety disorders and so like GG ad phobias got some notes on stress reactions for you guys. And so like PTSD and suicide risk factors and pro protective factors. Er, some notes on delirium versus dementia and some notes on somatization disorders for you guys to read about uh later. Yeah. Thank you for coming today. It was a very heavy session. We covered a whole lot of adult and child psychiatry. I hope you guys found it useful. Thank you for sticking with me um all night. Um It was uh we covered a lot of content. I hope you guys find it useful. Please fill out the feedback form. Um, I, if you guys can fill out the feedback form on personality disorders as well, I'd really appreciate that how we found the teaching as well. Um, but yeah, thank you for coming in. I'll see you guys soon. I'll, I'm off on my elective, um, now, er, next week, but I'll be back um, to teach um, one of the osk sessions as well. I think I'll be back teaching the chest X ray session, er, as well in a bit. Um, but yeah, er, good luck for finals, er, if it's coming up soon. Um, I hope, and I did a lot of your finals here. Might have done your, your PSA recently as well. It might be coming up soon. Um, so good luck for the result of that as well. Uh, but yeah, thank you and good luck if you guys have any questions as well, feel free to leave it. Um, I might have missed a few questions as we went along. But if you wanna ask them now, I'm happy to do so. Uh, will there be any more psych teaching? Um, I mean, hopefully I co I've covered most of the psych in this today's session. Uh, there we are doing psych in the Osk Osk series. There will be a psychiatry teaching which will be more sort of, um, er, um, obviously related to Osk. So things like mental stay examinations, how to do a suicide risk assessment. Um, you know, things like medication counseling and things specifically to psychiatry. Um, so that will be part of the Osk series. So there will be more specific um, um, OSK teaching.