Computer generated transcript

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

Um Hi guys. Thanks for being right on paying for this if you, because this is quite a, a lengthy um powerpoint just because, you know, it's like, like, uh if you have any friends who, you know, are wanting to come to this, just tell them to be as on time as they can cause there's a lot to get through. Um And also I'll put the feedback link in at the end just for you to um do the feedback to get the slides. I've done these out. So they can be used as like notes rather than have like, you know, 10 slides with one word on them. Pretty much. Every slide has the most of the stuff that you would need on it, right? OK. It's seven on the button. So I'm just gonna, is the full um presentation coming up there for everybody or can anybody not see it if somebody would unmute and tell me or put in the chat, please, we can just see the form for the um feedback, the peer feedback, right? That's not working then. So, all right, let me just share it again. Um Right. Can you see things it's a pink slide. It says psychiatry. Yeah, that's it. Now, there is that it, and is it on the full screen because I don't want you to see the answers and the um thank you, um, Catherine, right? So, um there's not that many people here, but I have to rush through this because it is quite hefty. So, um welcome to this talk about psychiatry. And psychiatry is a really, really fascinating specialty and sort of very different to everything else that you learn in um medicine. But it's quite fascinating and it's one of those diseases that you can't really see or sorry, psychiatrist, full of diseases, you can't really see and it sometimes makes them quite complex for in terms of and um MC Qs, normally it's very clear cut, but in reality, it's not. So just as a general rule um for all psych histories and um you know, presentations examinations just do a full history and people often get confused between a mental state exam. That's your appearance, behavior, mood, thought, perception, judgment, um psychosis screen and a history which is, you know, um presenting complaint, history, presenting complaint, mental health history, medical history. And II would be able to differentiate the two because I know when I was running OY for my lot and um it was, it was tough to know what was a mental state exam and what was a, a mental health history. So I would have those quite slick the questions are all the same, which is good. You don't to learn any new questions but definitely change the structure depending on what you're doing. Always be medications. A lot of medications can trigger mental health issues. The ones you're looking out for are any antidepressants? Antipsychotics, obviously illicit drugs and steroids and particularly, um, people always have like a thing called Roid rage. Um, but yeah, steroids can make you quite depressed as well. So um consider an organic cause. Um it's organic until proved in other ways. So if you, you know, get your baseline bloods, anemia can make you very depressed and you know, renal failure can cause accumulation of toxins in the bloodstream which can then trigger psychiatric symptoms. LT ST FT S, you know, an infection can make old people can throw old people off their baseline B12 and FOLATE. I don't know if any of you ever saw that episode of house where the lady had ate and end up smothering her baby. But there have been real um cases where people have sort of defended their crimes with a very low B12 and folate um to appropriate serology. Um syphilis and HIV test and sorry, this lights flicker in here. Um But syphilis used to be widely tested for in nearly all hospitals, particularly in people coming in with confusion. A lot like syphilis used to be endemic. It used to be all around. Interesting fact, the guy who discovered Tourette's syndrome actually had syphilis. Um, so, yeah, syphilis, neurosyphilis in particular, um, causes a lot of psychiatric symptoms. And, um, you'd be looking for things then like your Argyle Robinson Pupil, your, um, or it's called prostitutes pupil because it accommodates but it doesn't react. So that's the kind of stuff you're looking for as well, toxicology screen. And people always talk about a tox screen. There's very few drugs you can actually test for and you test, the urine tends to be not really blood, a physical exam. If you find a neurological sign on an exam, you might want to ct head just to make sure depending on whether it's an upper or lower motor neuron lesion. Normally, upper motor neurone lesions, you might want a CT head lower, you might just want a CT or an MRI of that specific part of the body. So anyway, onto psychiatry, psych crosses over with neurology a lot. Um And in, in some countries in Hungary, actually, they're the same specialty. So we'll start of depression. Depression is the presence of two core or three other symptoms for two weeks or more with an impairment on affected daily function. And that's quite, that's not the typical definition of depression, but it's the one that will definitely get you through your exams. The ones you're looking for are low mood. So that's quite obvious and hid, which is the loss of pleasure. Because if you think heaven is pleasure and hid is the loss of pleasure and ania which is lack of energy. But because of those sort of core symptoms, you will also get other things, weight changes, weight gain and weight loss. Don't just think of one or the other. It's both. You can. Some people will eat. You've probably heard of eating your feelings. Some people eat loads when they're depressed, some people will eat nothing and particularly people who go into catatonia will lose weight because they physically are not able to eat disturbed sleep again. In both ends of the spectrum. Psychomotor retardation or psychomotor agitation. Psychomotor retardation is essentially where someone's responses have been, you know, significantly slowed and that's, um, that can be somebody sitting who's very, you know, quiet and, you know, unreactive in front of you. Despite the fact that you're asking them direct questions, agitation tends to come in what used to be known as manic depression or bipolar. This is, uh, psychomotor retardation tends to come in unipolar depression or just no depression worthless. Listening to guilt. Nihilism, nihilism is essentially life's not worth living the world's going to end. We shouldn't do anything because nothing's worth it, decreased concentration, recurring thoughts of harm, death or suicide. It's also a mimic for dementia, which is very important. You'll have seen it in your M CQ. Most definitely. And dementia and depression crossover quite a bit, particularly in the elderly because if you think elderly people have lived very long lives, the longer the life, the greater propensity for trauma, therefore, they're more likely to have experienced some kind of thing that would trigger them into depression. And that can be like the death of friends and family or, you know, feelings of, you know, worthlessness because they can't do what they used to. Um, so depression in the elderly is a big mimic for dementia. So the clinical diagnosis, it's just you speak to somebody, there's no score, there's no blood test, there's no exact word that needs to be said. It just has to be, you know, your clinical impression and doctors tend to be quite good at um, giving the clinical impression. You can use the PHQ nine and less scores, less than 16 is less severe score, greater than 16 is severe depression. The one issue that I have with scoring systems and some people have with scoring systems as well is that they're on a set scale of answers. So, if you know this person very well, then you might know that they have severe depression, but they might not score highly based on the the typical symptoms. So, um, it's better to use your clinical judgment and then say in an OQ, oh, I would use the PHQ nine and that's, that's my opinion. Anyway. So, um, you can, these are investigations, you can do um, a blood count for anemia. Very rare that anemia actually is the true cause of a depression. It might just be comorbid thyroid function, test, hypothyroidism, uh Vitamin B deficient, it tends to be your deficiency that cause you depression, uh imaging CT head. And there's these theories that where the lesion is in the head is um sort of indicative of what pathology it will cause. So it, there's a focal lesions can lead to agitation and that's way beyond the level of what you need to know. I just know that you could do a CT head if somebody had neurology and depression or neurological signs and depression treatment for less severe is just self help. Um And it's, it's quite actually good to look at those, see if you can sit in on a session or, you know, get like the page that they give you because it, it actually is quite helpful to understand what self-help actually is. And it's a lot and it takes a lot to do. And when you think somebody who has lost their, you know, will to enjoy things and their energy has to take themselves through a list of activities and a list of thought programs. But then for treatment for severe, which is the one that comes up more often, the combination of CBT and an antidepressant and go on to the next slide, we'll talk about antidepressants. These are all the different types of antidepressants that you can get that you should know about mind journal and mind health are great sites. Um So SSRI S are selective serotonin reuptake inhibitors, think of serotonin as your happy hormone because it is the one that will, you know, balance you out and make you happy. So when serotonin is high, you're really overjoyed and serotonin is low, you're very sad. So if you inhibit reuptake, then it stays in the synaptic cleft, longer, the longer it stays in the synaptic cleft, the more action it has same with the SNRI S, it's just, it also does norepinephrine or noradrenaline. So as you know, adrenaline is your energy hormones, so it will help with your energy. They tend not to be first line, your TCAs your tricyclic antidepressants, they act in multiple different fronts which I've got in the next slide, your monoamine oxidase inhibitors, you, you shouldn't be coming across those anymore other than maybe the illicit market. Not that any of you are using the illicit market, I should say. Um but people don't, they don't tend to be prescribed anymore because they have a lot of side effects and you're no adrenergic and specific serotonergic antidepressants. I never used to understand the difference between the sero the SNRI S and the NASA. But the NASA target a different receptor set if that makes sense. So, ii quite like this table. Um you can sort of ignore the enzymes for the moment being. But if you look at reuptake inhibition versus receptor blockade, it'll tell you how all of your um drugs work. So if you look at amitriptyline, ATC serotonin reuptake inhibition, noradrenergic reuptake inhibition doesn't really have an effect on dopamine reuptake inhibition, but it does block histamine muscarinic receptors and alpha one. So that's how that drug works. And then you can see the potency listed here. You don't need to turn this table off. I just think it's very helpful into how it works. Mirtazapine is quite an interesting one. It's a NASA, not an SNRI uh and it's a, it has a massive histamine effect. So it's actually a very good sedative. So at a half dose of 7.5 mg, it's actually a fantastic sedative the sleep clinic in London and Harley Street, they use it for that purpose. Um but we use it in sort of general medicine and GP in psychiatry, it's used at 15 mg, which is a psychiatric dose where you will get the slight benefit of increased sleep, increased appetite. And then at high doses like 30 you actually lose that effect because it becomes less of a histamine blockade then which is very interesting. Sorry, I'm probably that's not something you need for exams, but it's just a always very interesting to know how these drugs work. DULoxetine is also very useful in chronic pain. So if you're looking at your chronic pain patients who have mental health issues or as a result of chronic pain, DULoxetine is fantastic. And then I'm trying to think buPROPion is good for anxiety. Sertraline is the most common one used. Um, I haven't Venlafaxine is there as well. Venlafaxine is quite new. So you'll see it coming in. Um, more in practice than in questions. And you actually stopped talking about antidepressants. Well, I won't actually, oy, a great Osk is antidepressant counseling and I would always go with the SSRI, I remember to review it 1 to 2 weeks after commencing one week for under 20 fives, two, for over 20 fives. remind people that it will take four weeks to work because a lot of times people, you will give people a tablet and they go, oh, I'll feel better immediately and that's not the case, particularly for mental health issues. They don't resolve overnight. It's not a sore toe. Um You must continue for six months after symptoms resolve not after drug start, not after getting over. Um you know, the initial bad feeling of taking an SSRI you have to be sort of feeling normal and then six months. So the choice is age dependent under eighteens, always go with FLUoxetine adults, sertraline and the elderly sertraline or Mirtazapine. As I said, Mirtazapine stimulates appetite and enables and encourages sleep, which is really good in old people because old people don't sleep that well because of the natural change in the cortisol cycle, they get up more also because, you know, things like need to urinate urinary retention, you know, or you know, urinary frequency, a lot of the time. Mirtazapine can help people sleep through the night. Important to know that side effects, caution people on suicidal ideation. It's, it's quite dangerous if you don't because then they just think they're getting worse and they might hurt themselves. Sexual dysfunction is very important, particularly for young men and women. And if somebody, men with erectile dysfunction can become quite depressed. And a lot of, there was, there was some research, now it's fairly flaky research, but there was some research into the people who sort of got the worst suicidal ideation were also the people who suffered from erectile dysfunction, who all happened to be men when they started taking an SSRI. So it's, it's quite interesting. But um it be sure to caution that particularly in young people, weight loss, nausea, vomit hyponatremia when you're studying for your psa, just remember um a sort of a a killer combination is omeprazole and sertraline. They will um you know, increase uh your sort of sodium loss. So you get hyponatremia bleeding. So when you're prescribing nsaids alongside it, give a PPI reduce sleep. Occasionally it can reduce your sleep. That's just sertraline, not really mirtazapine, uh discontinuation, use the acronym finish. So flu like symptoms, insomnia, nausea, imbalance, sensory disturbances and hyperarousal, never ever stop taking an antidepressant. All of a sudden you have to wean people off it and that can take four weeks. And if you're stopping one antidepressant and starting another one, there is going to be a crossover period So you need to build one down and build the other up. So we'll talk about serotonin syndrome here. So, Serotonin syndrome, you get people that come in complaining of a headache, they're agitated, they're hallucinating, shivering, sweating, they're quite high temperature, myoclonus, hyperreflexia tremor. So people remember that as the tricky frog, which is a nice way to remember it. 45% of people get fever and 30% get dilated pupils. The big causes I've listed here is traMADol and ecstasy triptans as well. So, um you know, like Sumatriptan for migraines and ST John's wart, ST John's wort interacts with everything. Um particularly, you know, your young women out at festivals, young women are more likely to die when taking ecstasy than any other group for some reason. It's really not known the mechanism. But um so particularly young women on an SSRI you have to counsel them, you have to ask them quite outright. Are you taking ecstasy? Are you taking traMADol? Because those two are quite pathognomonic for causing serotonin syndrome. Also anybody with migraines that comes up quite a bit in past me. I think the management is to stop all um serotonin um affected drugs and sometimes you need Cipro for that. I can't even say it Cipro hepat and but very rarely that would be like a consultant level measure. So is another treatment for depression. It's very important that you know what CT actually is because there's been counseling ect in previous ACUs, you're inducing a seizure using bioral electrodes. That's electrodes on either side of your head. Everybody has this opinion that it's this thing from one F over the Cuckoo's Nest. Or if anybody watched that movie Suicide Squad where you bite down on something and they shock you. It's really not that way. It's not that exciting, to be honest, it takes like 15 minutes. And, um, yeah, it's not that interesting. You have to do it under A G A. So um if you went to Mars anesthetic talk, she'll have talked about a general anesthetic, um tends to be a drug induction and propofol and maybe a bit of fentaNYL and an antimuscarinic or sorry. A muscle relaxant like rock uronium or atracurium because it's quite short acting. The only absolute contraindication is raised CP. Um If somebody has raised ACP and is catatonic depressed, you might wanna consider another intervention because raised ICP. If you essentially what can happen is you can sort of herniate your cerebellar tonsils at the back of your head because the seizure will increase ICP. So if you increase ICP to the point where the tonsils, herniate, you'll have killed the patient and they'll die like there's, there's no coming back from a herniated tonsil or cerebellar tonsil. So, um we monitor using E EG ECG and E MG. The most important one to know about would be the E EG and the ECG um just I've got them on the next slide and I'll show them to you the short term side effects, short term memory loss would be the most important one immediate elevation of mood. I've seen it before when people come back from a CT, like I feel fantastic and they're so high because essentially they've all of their, you know, serotonin and all of their neurotransmitters have just been released into the synaptic cleft. It's like um depolarizing the membrane without actually having to have that big sodium cycle going on. You can also get a cardiac arrhythmia, which is very important. So if people have cardiac arrhythmias, it's not an absolute contraindication. But you have to proceed with caution and long term, there is a link to dementia. Some people there have been studies that and fairly robust studies that show people with prolonged courses of ECT normally can get a small amount of memory impairment, how much of that is related to age and how much of that is related to the ECT. The ratio is not really known. It's also kind of important to note that uh you'll do it two times a week. So I know in the Western Trust, the CT Center for the southern sector of the Western Trust is a A does two sets of CTA week. So it would be a Tuesday and a Thursday and people would go in, get crossed over from the psych unit, go in, get counseled every single time on how CT works. So you've got to remember, not every person will remember it, particularly if it catatonic. So it's very important to have effective co and I would know how to counsel act. So this is the side I was telling you about. So if we start up here at section A immediately after stimulation, you can see the E EG starts to fibrillate and I'm not going to get into the types of brain waves because that's far beyond the need or far beyond what you need to know for finals. And I'm not going to confuse you with that. You can see during the seizure, the seizure activity gets quite intense. The E MG here is not recording for um for a reason, the ECG also increases in rate. If you notice that you can also get a lot of artifact because somebody is may seize, you don't want that seizure to last more than 10 seconds because if somebody is seizing for more than 10 seconds, then it's likely the blood is not properly getting to the brain. And then just before the termination of procedure, you can see there's an arrhythmia actually in the um the rhythm strip here. So if you see ECG change near the termination procedure, there's also an arrhythmia. So it's just very interesting to note. Um Am I making sense so far? I also, I have to say I have the chat um here, if anybody has any questions, please put them in the chat. If I don't see them, I'll get to them at the end. Um So we'll move on to bipolar. There's two main types of bipolar, there's bipolar one and bipolar two. The important principle of bipolar that differentiates it from EU PD and cyclothymia is that you have to have mania and depression. So bipolar one, you've had at least one episode of mania. Bipolar two, you've had at least one episode of hypomania. And the difference between mania and hypomania is that mania is beyond the realms. It's fantastical. It's, you know, visions from God, you know, I've been chosen kind of issues. Hypomania is more, I'm going to clean the whole house in the night. I am able to go to work. I'm able to, you know, live my life. It's just not the way I would normally live it. But you also in bipolar two, you also need to have an episode of major depression and the management, you basically manage this based on what the problem is in front of you. So, am I managing acute mania? And that's a trial of oral antipsychotics. ARIPiprazole is normally the first line antipsychotic. The problem with ARIPiprazole is it's a very good drug. Don't get me wrong. But um less people respond to ARIPiprazole than to the other older antipsychotics. And if you can manage an ARIPiprazole, it's a very good drug. But if you can't manage an ARIPiprazole, you can't really, you know, increasing the dose won't do much. But omeprazole haloperidol is very good. But you have to watch Haloperidol in your Parkinson's patients and your Lewy body dementia patients. OLANZapine is quite good. It's also used in the rapid track um protocol risperiDONE. It, it does very much depend on the patient context in the clinical context. But if you have a question that says management of acute mania, you're probably looking at an antipsychotic management of acute depression. Remember that when you're treating bipolar disorder, giving someone an antidepressant will trip them into mania because you're elevating them and you're not allowing them to come down the best combo. And the combo that most commonly comes up in questions is FLUoxetine and OLANZapine, you can use the others as well. LamoTRIgine. Um You will notice is actually an anti epileptic, but it's an excellent mood stabilizer. And then if we also cognitive behavioral therapy is good, but I will warn one thing about cognitive behavioral therapy. You have to wait until someone's stable to do CBT, not manic and not psychotic. You can do it in depression when they are depressed. But for the manic patients, I would always, you know, hold off on CBT until they're at a stable enough level to sort of interact and interpret everything correctly. So if we talk about mood stabilization, that's your lithium and lithium is a very important drug that I would know a lot about for my psychos sodium valproate. But you have to be on the pregnancy prevention plan and that involves going getting a monthly pregnancy test being on a reliable form of contraception. And for patients like this, the most reliable form of contraception might not be a pill, it might be a bar or it might be a coil or it might be the depo injection because then that way it's sometimes people who are manic, forget or choose not to take their medications. It is a real problem amongst like compliance is a real issue amongst people with mental health issues because they have mental health issues and it's, it's not out of laziness or out of, you know, rebellion. It's just as part of their condition. They may struggle to remember to take medication. LamoTRIgine is also very good as I said before. Um it's good for mood stabilization. You have to build these drugs up though. You can't just start at a very high dose referrals. Um I would always if you're a risk to yourself or others because you're either manic or severely depressed. Um urgency referral to the community mental health team or admit as an inpatient. If you're hypomanic, it's a routine referral to the community mental health team. And I know that that's very hard for some people to get their head around. But hypomania very rarely causes people to do anything to themselves or others. It just causes them to be a bit more elevated than normal. It can have progress into many. You do need to get it seen too. So monitoring, these are the most important monitoring I know about is lithium. So lithium needs to be taken 12 hours after the dose, take a dose taken and sorry, the blood is taken weekly until the levels are stable, decrease them to once a month and then once every three months. And that's something that can be quite difficult to get your head around. You need six monthly thyroid function tests because I think can hit your thyroid quite badly. You and E and calcium and this is just so rapid cycling is also something that comes in. It's, it's different to bipolar. It wouldn't be a true bipolar. Um So you can see here bipolar when we up to extreme mania and then down to depression and this might be over the course of days to weeks. Whereas something like emotionally unstable personality disorder, you're getting that pattern in a day rather than over a couple of weeks. Psychothymia, you're never truly manic. You might be a little bit hypomanic and you're never truly severely depressed. You just sort of go through this cycle. It still can be very difficult for people to live with because this change in mood and change in feeling is, is quite disturbing, but it tends to not go as, as harshly as bipolar. It very rarely comes up in question. So it normally tends to be either bipolar one or bipolar two. So lithium counseling, it's a real key point of. You have to take it at the same time every day. Never stop taking it suddenly and mention it. It's really important. You mention the lithium record book. It's a little yellow book and it basically will, you'll write down all of the sort of what lithium they're on. What's the brand name? What's the dose? You know, what are they, you know, what form are they taking it in? Is it tablets? Is it liquid tends to be tablets. You never aa dose of lithium. If you've missed one, you just take the next dose again. All really important points for counseling any drug. But this is in terms of lithium, lithium can induce birth defects. And I believe um it's particular cardiomyo or hole in the heart. It can cause uh first trimester pregnancy. Uh So concer as well can also cause um birth defects. You have to use a reliable method of contraception if you're on lithium. And because it can also be passed through breast milk, I should say. But um it's really important that you're on contraception. If you're not planning on getting pregnant and if you are planning on getting pregnant, you need to change off to normally to something like lamoTRIgine lithium toxicity. I'd learn off that list of symptoms for lithium toxicity. It's really important to not only be able to recognize it to be able to tell people this is lithium toxicity, you need to go get seen. And normally that would then mean, you know, reducing the dose, the side effects actually spell it. Lithium, which I think is quite fun. Um So lethargy and diabetes insipidus tremor, hypothyroidism. Hence where you get your TFTs measured gi upset, it can be quite rough on the old tummy urine. You'll um you start increasing a lot or you increase the volume of urine, but like diabetes insipidus and you get a metallic taste in your mouth. But I suppose you are swallowing what is essentially an apple. So it can give you that me taste, avoid nsaids and cannabis because they increase the amount of lithium in your system and that can lead to you to go into toxicity. So, schizophrenia, I the things I would know for schizophrenia is very vast and it, it is different in every single patient. These are probably well aware first rank symptoms, learn those off and ask them in every single history you take in psychiatry, whether it's a mental state exam or a history, ask your first rank symptoms. But and it's Schneider's first rank symptoms as well, not to be confused with anybody else's and make sure you know them, make sure you know what they mean. So, auditory hallucinations that includes running commentary, voices, conversing. So some people will have just two other people having a conversation but it's in their head which is very, it's like constantly going around with two people ignoring you or talking about you, which can be very upsetting somatic hallucinations in the absence of cause. So people, when they get the delirium tremens, when they're withdrawing from alcohol, they'll get a thing called Lily potty and delusions, which is where like little things are crawling all over them. That is cause. So therefore, that is a somatic hallucination of cause. So in the absence of cause like someone's touching my arm or there's something on my arm or you know, there's someone pulling on my ear, that's a somatic hallucination without cause. And that is what would be schizophrenic rather than another cause, delusional beliefs. So that could be I'm the son of Christ or you know, I am going to lead the world into a new revolution. I can talk to dogs, those kind of things, thought withdrawal in someone pulling the thoughts out of your head. So you might be thinking about something and maybe due to schizophrenia, they can't focus on that thought and they lose it because we all lose a thought. It's like walking into a room and forgetting why you're there. That's kind of thought withdrawal. That's not problematic. That's like this but all the time. So they'll be thinking about something like, oh I need to go to the shops and I need to buy milk, jam and bread and then that thoughts pulled out of their head and they go, I needed to go to the shop and I can't remember why someone has taken that from me in certain interruptions. So that might be whoever, you know, somebody I suppose will say putting thoughts in your head or taking thoughts, you know, and stopping you from thinking or talking over your thoughts, thought broadcasting is, then they're passing your thoughts out to the rest of the world or they're sharing your thoughts amongst the council. And passivity is the concept that you are not in control of yourself or your own life that there is someone or something like it might be God, it might be a parent. It might be a sinister figure or, um, you know, a cabal of some kind that is in control of your actions and in control of you, which is very frightening. Um I think what we need to, people forget about schizophrenia is it's not a nice condition to have. It's extremely frightening for these people. And I think if we were all having to go through what they went through, we'd all think like this. You know, it's, it's almost like, you know, it, it's hard to say they're delusional because in their head, that is true. It just, it's not true to us. So you need at least two symptoms to be present most of the time for at least one month. We'll talk about positive negative manic psychomotor and cognitive symptoms in a wee minute. You don't need to know that much about them. But um one core symptom needs to be present. So, disorganized thinking can be hard to pin down because what I might call disorganized, you might call normal. And we've talked about delusions, we talked about hallucinations, experience influence passivity or control and the symptoms are not a manifestation of another medical condition. So if you think of Cushing's disease, you can get quite bad mood swings. Polycystic Ovarian syndrome, you can get bad mood swings. So it's very important, you know, and people on cocaine as well, that's another one. Actually, I'm thinking of medications. Um and paranoia can be triggered by weed. Um I don't know if you've ever seen like on the TV. And all there's always those sketches about people who smoke weed and they're really paranoid that they're being followed around. That's kind of what that's like. So um if we're talking about positive symptoms, that's where something is happening. So I would say like hallucinations, seeing things, delusions, those are things that will make you go out and do things. So I always think positive is action, things, disorganized, speech and thoughts is the muddling up of thoughts. So, II always think of positive symptoms as actions where negative symptoms are again, anhedonia, much like depression. So you can see how you could have a psychotic depression. Abolition is the lack of motivation and a blunted affect. So it's very important that you might see somebody and you think, oh, that's depression, but it could actually be just negative symptoms. Schizophrenia. So it's very important then you have to take a full history and talk about all of these things. This is why you screen for your first strength symptoms, cognitive symptoms. There is this sort of thought that, you know, people assume schizophrenia is not, in fact, doesn't affect people's intelligence, it actually does, it can make you forget things. You know, you can almost have a bit of almost like a sort of the interpretation of the world the same way sort of autistic people do. You can't process social cues, your, you know, sensations might become uncomfortable. So there's a lot of blend over in these different conditions. So it's very important that you take a really thorough history, impaired sensory perceptions. You know, people might feel like they're in a cage because the window shut, the feeling of air moving can be really uncomfortable. Sort of giving me these examples from really clinical practice that I've seen the management. However, is antipsychotics and typical antipsychotics first gen. So your halo Peridol, your levomepromazine, which are actually also very good for nausea if any of these have done palliative care and they use them quite often because they're very, you know, sedating as well. So it stops people feeling sick. Your atypical is your second gen, that's your OLANZapine, your risperiDONE, those kind of drugs. CloZAPine is a sort of a class on its own. You have to have failed two previous treatments and one must be atypical to get um cloZAPine. CloZAPine is quite a harsh drug on the um on your body. Um but six out of 10 people with treatment resistant or who failed two previous treatments will benefit from taking cloZAPine. So it is a very brilliant drug, social intervention really only went stable and that's helping people find housing and stuff like that um to stabilize them and encourage, you know, good influences on them, you know, to go and get help when they need it. So terms to be familiar with for schizophrenia, schizophrenia is quite a large one, pressured speech, circumstantiality for people. You'll ask them a question like, how are you feeling today? And they go, I'm feeling good, but yesterday I was feeling bad and I was feeling bad because so they sort of talk on and on. Some people refer to me as the way old people, elderly people have conversations, you know, they'll tell you something and then they'll tell you something else that leads on, but they'll circle back to the original point. Eventually, tangentiality, they will just jump from, you know, they'll start at one point and then suddenly you're at the other end of the spectrum of conversation. So I always use this example while I was riding my horse, it was so sunny. But I suppose that's normal for this time of year. I prefer the summer months. That's how did you hurt your arm? Doesn't really answer that night to move. Thinking is just nights move is a chest move. Um And it basically, it's quite erratic. So you just sort of jump from point to point. A logicality is, as it says, clang associations are sort of words that sound similar like Fang Bang clang. Um perseveration is um essentially where you're just uh people call it persevering, but you're talking through with one point I believe. And echolalia, the rep repetition of sounds. So poor prognostic indicators for schizophrenia are young with a strong family history, gradual or prodromal symptoms. So if it's a build up, if you have sudden schizophrenia, that's actually a better prognostic indicator and low IQ, they tend not to respond to treatment so well. And also then they lose if you're getting cognitive symptoms on a low IQ, there's not much further. You can fall. Neuroleptic malignant syndrome is something I'd be very aware of. Um metabolic reaction induced by antipsychotics. It usually starts early in the treatment course. So they'll just have been on the antipsychotics a couple of days. There'll be pyrexia, muscle rigidity, hypertension, tachycardia, tachia, you need to stop the medications, admit them to the medical ward IV fluids and then you, it's a consultant level intervention, but Dantrolene is also an option. Extrapyramidal side effects. Sorry, I'm, I'm rattling through this because I don't want to keep these too long drug induced parkinsonism will always give you bilateral symptoms and that's how you differentiate it from um, normal Parkinson's and normal Parkinson's give you unilateral symptoms. Eutheia is restlessness. So you'll see people fidgeting, unable to stay still acute dystonias or you're sticking torticollis, ocular gy crisis, which is where your eyes get stuck in a certain direction. You have to treat them with procyclidine, which was a question on the mock PSA and then tardive dyskinesias. Are your movement? Chewing and poutings. You can, there's great videos on the internet of those and I would have a look because they could show you that in a video in an ay and then ask you what's going on and how do you treat it? CloZAPine. So we've talked a bit about cloZAPine. I'll let you read through this yourselves. When you get the slides out, cloZAPine is, there's some points I want to raise about cloZAPine is the big side effects. You need to worry about agranulocytosis, lowering the seizure threshold and constipation. So you must co prescribe a laxative. There have been cases in Northern Ireland within even the last year where people have not been prescribed a laxative with their um Clozaril or the cloZAPine. And as a result have ended up in the ac because Czar and sorry, Czar is the brand name of cloZAPine. That's why I keep saying it. Clozaril can induce constipation. That is fatal. And that sounds quite, you know, people go oh yeah, it's just a bit of constipation. No, like if they get constipation like you have to give them a laxative, normally a stimulant, laxative. So, monitoring the drug for the 1st 18 weeks, you're checking the bloods either weekly and then fortnightly after 18 weeks and then monthly after a year, you need to be measured or monitored through a system for agranulocytosis. I believe the one we use in Northern Ireland is ZTA. It's definitely going to use in the Western Trust and I think in the Northern Trust as well and then plasma levels of closing aren't really checked. Unless there's proof appliance. It can cause you to get an arrhythmia and a cardiomyopathy. So you need to check an HCG BP and pulse can go up and also can go down calculation of BMI as a lot of these drugs can cause you to put weight on. And then your laboratory investigations also really important to note you get a one year license when you're on cloZAPine. And it's because people can relapse. So you need to be stable on treatment for at least a year. Um and then it has to be reviewed yearly. So it is a way that people then don't fall out of treatment. There's a big issue in psychiatry with patients either, you know, not presenting themselves or not having the resources to present themselves to get help. And as a result fall out of treatment programs, this D VLA one year license because people need to drive is a way to keep people involved in treatments. And then if the D VLA picks up somebody who's, you know, essentially psychotic, they can then go right. You can't have your license and you need to go to a doctor to get stabilized, then they have to go to a doctor. So it's a great way to keep people in treatment. These are all this is what we've gone through about antipsychotics and just remember the difference between typical and atypical. We try not to use typicals anymore because they have such bad extrapyramidal side effects. The most of the side effects tend to be worse with um your typical which is your haloperidol a new Levo. But um just remember um for a prolonged QT torsade de pointes or torsades, de pointes or twisting of the points of your RP. Um but treat with magnesium and magnesium is a brilliant drug for a lot of different conditions. But just remember for this one and I'll let you read through that again. It's very similar to cause of pain. We got to go through our delusional disorders. You get these quite often in MC Qs, you don't really get them in um Aussies because they're, they're quite a crossover with a lot of conditions. Romania. If someone's in love with me often tends to be, you know, somebody famous. Um I think there's a very, you can see it a lot online through paras social relationships and you know, like somebody will obsess over a celebrity, contacting them, tagging them, you know, sharing their posts. It's quite, um it can be quite, we call it, there's a line between being a fan girl or a fan boy or a fan person and being, you know, a roto manic. So they call it the Cla Amol syndrome. Amol was a, a psychiatrist, grandiose type or megalomania. And that's the inflated self worth power and knowledge tends to be cult leaders. I don't know if any of you ever watched that documentary about this woman called, I think her name is Amy Carlson. She was the cult leader of a cult called lover's one. But she had that grandiose delusion that she was going to be bringing forward the, uh, bringing in, you know, a new age and she was a savior and she quite genuinely believed it. It was, um, so that's the grandiose type. They believe their own hype jealous type or a fellow syndrome, which is very poorly named because that tends to be people who think my partner's cheating on me. They, you know, and then they check the partner's phone, they're hunting through, you know, their car, they're tracking them, you know, they might be setting them up, you know, paying somebody at their work to go and ask them out to see what they say. It's named after a fellow, the Shakespearean character. It's very poorly named because a fellow was actually right, his wife was cheating on him. So it shouldn't really be named after him, but that's essentially what they, um, have decided to name it. So there we go. Persecutory type. It's very, very common people believe that they're being persecuted and it could be by a genuine person, someone who's sitting in front of them or is real or it could be someone who is, you know, in their head or, you know, it could be part of their delusion and they may seek justice by making reports taking action or acting violently. So it's very, it's, it's important to keep these people grounded and, you know, sometimes watched particularly if they have a history of violence, somatic type, physical defects, you know, or people feel things like people touching them mixed and unspecified or essentially where you have some combination of these that doesn't really fit one entirely and co her's delusion of the walking corpse syndrome. This person believes that they are dead do not exist, they're puting on the inside or they've lost their blood or internal organs. It's sort of a form of nihilism. Um But it's quite specific again, Coard was a, a psychiatrist, so we'll move on to personality disorders. Here, there are three clusters, cluster A is all an eccentric cluster. B is dramatic and erratic cluster C is severe anxiety and fear. Um Someone told me C for cowards, I don't like that, but it helps some people remember B for the B word because um I'm borderline, that's how they tend to remember that. And then a was, oh, well, I don't really know because they're quite strange. But again, this is the big table I use to learn these off. There's some, I would know about, um, in detail, borderline personality disorder slash emotionally unstable personality disorder is the other name for it. I would be very, very aware of that one antisocial personality disorder or the so called psychopath, which is a very bad name for it. Um I wouldn't be so aware of that because to me, the true psychopath is extremely rare, although you never know narcissism and narcissistic personality disorder, it's a bit like grandiose delusions, but they're actually grounded in reality a bit. I would know about schizoid. Schizoid is the void. So that's how I remember it. And schizotypal is people who are, you know, quite, they're fantastical and they believe in conspiracies and everything is brilliant uh and magical. That's what schizotypal would be. Um not to be confused with schizoaffective. So I PD, I would differentiate quite heavily from OCD. OCPD is essentially someone who does things their way, their way only and it's their way or the highway. So they are very orderly, very perfectionist, extremely controlling of the environment. Whereas obsessive compulsive disorder will get on to in a minute, it's completely different. There is a sort of almost overlap, but it's quite different. Eu PD. So the way I remember, eu PD is they're social comedians they will change to fit certain social groups, certain friend groups, certain family groups, they struggle with perceived or actual rejection and romantic parental, social and even para social relationships. Um, the, the famous example for this is, I don't know if anybody's ever watched Star Wars but, um, Anakin Skywalker is like the poster boy for, uh, borderline personality Disorder, supposedly. Um, I've, I've not watched the full of the films, um, but I was reading up online and yeah, he's um he fits a lot of these like extreme reactions to perceived rejections. I think he um his mother passes away and then he goes spoilers. Um his mother passes away and then he goes and massacres a village. So you can see that kind of extreme reaction and normally U PD, it tends to be um you know, break, this is the question you get, which is actually quite insulting to people who have AU PD. Is the boyfriend or the girlfriend broke up with them? So they self harmed it. That does happen. Don't get me wrong. But it, it's a much more complex condition than just I got. So I hurt myself. It's, it's very important that you remember that. So um a lot of these people also have been through trauma, like quite severe trauma, a lot of the time there's sexual abuse involved and there's trauma scales you can use to sort of help treat people. It's very important to know what kind of trauma, they've been through as well because if someone's been through sexual trauma, it's going to be very different, but, you know, managing people who have a history of violent trauma. Um But there is potential for these people to have great kindness as well because they feel so intensely. They are like boiling pots where, you know, if you turn the heat up and they get very irritated and feel rejected, then their emotions just blow. But then they also have this propensity to be extremely kind to people. Some in an attempt to gain, you know, um favor. But you know, kindness is kindness. The management is dialectical behavior therapy. These tend, these people tend to not need medication. A positive action plan is put into people who are admission into an inpatient unit after a suicide attempt. And what that is is it's a 72 hour admission plan for, what are we going to talk about? What are we going to do? What's going to be the psychological intervention? And it's important that you limit the time in an inpatient setting to 72 hours because they are social comedians. They will adapt and learn the behaviors that people in the psych ward are doing. And, and 11 example I saw was there was a girl in the psych unit who was a schizophreniac, she was having severe hallucinations and delusions and she was very frightened all of the time. One of the patients then didn't want to be discharged because you have to remember that the psychiatrist might be the most stable relationship that this person has in their life. Why on earth would they want to leave? Essentially the only person who may care about them? And that can be quite frightening for them? So she said that she was having hallucinations. And the psychiatrist asked, are you aware that they're hallucinations? If someone's aware that it's a hallucination and not real, that is a pseudohallucination. So pseudohallucinations can come in AU PD can also come in grief. So that's the difference. So you can see she learned that behavior from another patient with a different pathology and then try to replicate it. And it's worth noting that a personality disorder is not a criteria for detention and it's not a and I suppose it's not a true mental illness. It's a mental difference. Personality disorders aren't illnesses in the way that schizophrenia is, it's more the way people interact with the world. So when people always say there, there's this horrible phrase that people use. Are they mad or are they bad? And you would suppose mad might be somebody with schizophrenia, bipolar or bad, might be somebody with a personality disorder. They have the choice and the ability to say no to their impulses, they just choose not to. That's sort of where that comes from mad versus bad is a very old school and a very outdated way of thinking about it, but it was the way that helped me kind of understand the difference. The key characteristic of take away from AU PD is their impulsivity. When you're doing a risk assessment, a suicide risk assessment, particularly on people with the UD, you'll notice that they say that it's uh it was an impulse decision. I was just so annoyed, so upset or so hurt that I hurt myself or I tried to kill myself. That's where AU PD differs from other types of emotional dysregulation. So your anxiety disorders, your dad versus your panic disorder, your panic disorder is present for at least one month. Whereas dad is six months and it's dad is this free floating anxiety. They're constantly anxious about rational things. Whereas your panic disorder tends to be your physical symptoms. There's, there's no stimulation, there's no cause, so to speak of the anxiety. Now, the, the treatment courses are very similar. So you can see it's active monitoring and education is first line low level CBT, high CBT, an SSRI for G AD and CBT. And then 12 weeks of an SSRI for um panic. And then you can use clam, which you can also use an OCD um for panic and beta blockers for symptoms in G AD, which I think is I would just learn that table. You don't really get a lot of questions about anxiety disorders, maybe one or two. So OCD do not compete with OCPD. It's not technically an anxiety disorder, it comes in two parts. The obsessions, the repetitive and persistent thoughts, images, impulses and urges and a lot they're not wanted. So a lot of the time they can be violent, they can be sexual, they can be extremely disturbing to the person that has them and everyone else, the compulsion is the action performed to neutralize the obsession. So if you're worried your house is going to burn down, then you might um you know, unplug all of the devices and check that they're all unplugged. Um OK. Sorry, someone was asking there or how do you differentiate between anxiety disorder and panic disorder? I would go with the time frame. So six months, normally g about one month, normally panic. Let me see if I can go back here. Sorry. Um You might have worked it. I'm a complete low date with technology. So yeah, at least one month symptoms peak within 1st 10 minutes. That's not always the case in actual fact. And questions, that's how it is. The way I would differentiate it is time. Um unexpected, no stimulation. I again, it's very gray questions. I always went in the time frame and it normally worked out well. Women tend to get it more again. That's just probably, that's probably not even that true, but it's what it says in the textbooks. So I would, I would base on time more. Um But you can also look at these other factors Right. Perfect. Move on to OCD. Yes, low intensity CBT and exposure response prevention. So that's essentially where you take this person in and then, you know, you expose them to the thing that makes them obsessive and compulsive and then you try and teach them how to not do that, which is really, really difficult. And I'm saying it, it sounds really simple but it's not. Then you can use an SSRI like sertraline and then clomiPRAMINE is a tricyclic antidepressant and you can use that sort of last line. So eating disorders, II, understand that um, a lot, a lot of people will have eating disorders and there will probably be some people who might be listening to this, who have had a history with an eating disorder, these infographics, they, they're just for your sort of learning for the people who haven't been through these kinds of things. But um, they're not, they don't represent absolutely everything that you can get with an eating disorder. So, anorexia is one of the big ones to know about. It tends to be a BMI of 18.5 or less, but you can also have a rapid weight loss of greater than 20% in six months. So just because someone is not looking very thin or, you know, has a very low BMI doesn't mean that they necessarily don't have an eating disorder or eating disorder behaviors. And you can find, you know, bigger people can also have eating disorder behaviors in their attempts to lose weight, persistent pattern of restricted eating tends to be the key for anorexia. There's purging behaviors. Um laxative use, chewing and spitting tends to be more the end of the spectrum. Excessive exercise can also come with anorexia or orthorexia. There's a preoccupation with body weight and shape and the over evaluation of a low over evaluation of a low body weight. You can also find that these people get a thing called lanugo hair and Lanugo hair is this very thin layer of downy hair. Um kind of like the hair you get on babies to keep them warm because their body weight is so low and their body fat is so warm. Remember, body fat keeps you warm. Um So they get this little thin hair, they also get like a hypokalemia and they get um hypocalcemia. I believe there's a big list of all the electrolyte imbalances you can get essentially you can get, most of them tend to be low. Sometimes your growth hormone can go up a bit because you're trying to stimulate it. But um these are the types of eating. The treatment is CBT. You tend to not be able to drug people out of an eating disorder. People with eating disorders are also extremely clever, they will drink loads of water before weighing to weigh more. So it's very important that you know, you, you try and look for your deception mechanisms as well. So, um the next thing Children and young people is anorexia focused family therapy. No mental illness occurs in a vacuum. So if for particularly for Children who aren't really in control of what food is brought into the house, it's really important that the family are educated, you know, um it's not a mentally ill patient, it's a mentally ill, you know, family or a mentally ill household because there's, it's never just one person who's mentally ill. There's always issues in the house or issues somewhere else. So it's really important that you get the family involved because that increases treatment success. So go on to bulimia. Bulimia is binging and then compensatory behavior like purging and they have to occur together and again, the preoccupation um with weight or body size, you will get recurrent vomiting and then that leads to dentists normally find bulimia because they wrote the back of their teeth. They also get Russell sign, which is for people putting their fingers in their mouth, they're getting calluses on their knuckles because they've exposed their hand to acid and also a scraping their hand on their teeth. I get, you just refer to specialist care. It's very difficult to treat eating disorders. They're one of the most difficult diseases in all of medicine to treat. Again, group therapy, guided self help and Children again should be in bulimia focused family therapy. So for any disorder, it's not eating disorder, focused therapy, you can also talk about binge eating disorder. It doesn't really come up that much. But again, it's just, you know, these periods of high caloric intake sometimes followed by no caloric intake. So it's very important, it doesn't really come up that much. But again, it would be bulimia or um, binge eating disorder focused family therapy, acute stress for posttraumatic stress, very similar symptoms, but acute stress disorder occurs within the first month and posttraumatic stress disorder is after one month. Um EMDR is the treatment of choice for PTSD and then short term psychotherapy and medication is um, antidepressants is acute stress disorder. The symptoms are very difficult to differentiate even when you're reading questions. So if you think this is some kind of trauma, then get a timeline. Ok. The timeline is less than a month, acute stress, posttraumatic stress, more than a month and E MDR is quite um difficult to watch. So if any of you have been in with sessions with the MDR debrief, those because they can be very uncomfortable for us to sit and watch, very uncomfortable for the person receiving it as well, but very uncomfortable for us to watch as well. Substance abuse. Sorry, when you're in the end here, there's a lot to cover in psychiatry and I wanted you to be able to use these as notes. This is what you need to ask when you're talking about any substance. And also gambling, gambling comes into this as well. What substance, how much and quantify in terms of bottles, bags and spending. So a lot of us will be, the average medical student is somebody who is middle class. They don't really have a lot of experience with drugs and alcohol. And that's quite, you know, it's quite hard to get your head around the things people will do to pay for drugs and alcohol, you bottles. So if you know how much a bottle of vodka costs, the cheap bottle of vodka now is 20 lbs. So if someone's spending 100 lbs a day on vodka, you can around about estimate they must be drinking between four and six bottles of ab good. Whereas if somebody's, you know, buying cocaine. So if somebody says, oh, I get nine bags of cocaine a day, well, how much is a bag of cocaine? You know, we don't really know those things. So if you qualify in terms of spending, it can be a much bigger indicator for people like who haven't had that experience with drugs and alcohol, mixed usage is a really important question and a lot of people will, you know, maybe they'll use crack cocaine to get high and heroin to cool them down or they'll use benzos to cool them down and maybe use, you know, methamphetamines to perk them up. So it's really important to qualify if there's mixed usage because very rarely are people on only one drug effect on lifestyle damaged relationships, Children if somebody mentions, if somebody is talking about substance abuse and they mention Children that's social services, you have to get them involved. And it's not, it's not to say that people who have problems can't be parents. It's to say that when you're under the influence, if you can't drive a car, you can't raise a child. Health implications particularly for alcohol is quite important. And also, um IV, drug use, hepatitis HIV, sexually transmitted infections, viruses, balance disorders, falls, fights, even broken tubes, broken jaws. That kind of stuff. Ask about it. All. Involvement in crime and people will pay for drugs and alcohol through criminal intent. There's people who are victims of cuckoo, which is where a drug gang will live in your house and they will pay the person with drugs and it can be, it's a very awful form of control because people can't live in their own house. They just live in a room and constantly do drugs. It's awful usage safety. Um, where are people using drugs? So if somebody's injecting, are they injecting with others? Is there someone there to administer a reversal agent or call an ambulance are particularly during the pandemic home use became an issue. People were drinking alcohol and doing drugs in their own home. They'd overdose or they'd get fall or hurt themselves or choke or aspirate and there was no one there to save them and a lot of people died because of that reason. Pubs and clubs, particularly for the likes of GHB and your date rape drugs. Um, people who use date rape drugs on themselves as well to get a little bit high. Find out where people are using because then that could be, you know, that can be a triggering point for when they're in recovery. Are they using safe needles, safe snorting techniques? And if you're using a straw or uh a rolled up tenner or whatever it is that carries the same risk of hepatitis as using a needle. So it's really important that people don't share needles, but they don't share roll ups either. Do they have recovery medications? Which is your, um, naloxone for opiates, um, for, you don't give out FMA for Benzos, um, because it's a very risky drug to give out. So you don't use that, you don't give that out. Really the one you need to know there is naloxone who have they been in contact with about these issues? Sometimes it's nothing. And how bad are they to change? Because you're not going to change somebody who doesn't want to change. Screening for alcohol abuse cage, particularly even in gi histories like, yeah, you might get a psych station like counsel person on alcohol or, you know, talk to this person about alcohol. But, um, cage, even in the gi history is gold if someone tells you, yeah, I've got, you think it's an esophageal virusy run through a quick cage audit is too complicated for history. Um But it's a, you know, a checklist, you could come up in an M CQ complications of um this of alcohol, I should say six in withdrawal, 6 to 12 hours of sweating, tremor and tacky and PT people would say 36 hours is when your seizures start to kick in 48 hours to 72 hours is the day ts and they are very, very scary. It's your course tremor, your confusion, your delusions, your lily put and delusions that we mentioned earlier. Auditory and visual hallucinations, fever and tachycardia. And you manage with your Librium or your chloro epoxide, which is a benzo. You can also get wernickes encephalopathy, which is ataxia, nystagmus, ophthalmoplegia. It's caused by thiamine deficiency. If it's untreated, it goes into Korsakoff Syndrome. And then you get your an grade amnesia, which is the inability to form new memories and confabulation that is very difficult for people to live with. So it is worth if you're counseling someone on alcohol, you can say, listen, you can get an alcohol induced brain injury and this is the alcohol induced brain injury that you're talking about detox. So, using the C A tool to give the likelihood of needing admission and and just say that you don't need to know the C A tool off by heart. Um So longer term management is naltrexone, which is the blocks sort of conditioned reinforcement. It's an opioid receptor antagonist. So you're not really going to get the high off it because it blocks all that sort of feeling. It sort of helps you kick the habit. Can see it reduces cravings and disulfiram makes you ill if you take alcohol, which I think is quite, it's quite an impressive mechanism. Opioids withdrawal. It's essentially, if you give opioids you'll have side effects. And if you know the side effects of opioids, it's the exact opposite for withdrawal. So, opioids are very constipating. So, if you're withdrawing, you get diarrhea. Yeah, pinpoint pupils. If you're on opioids, you get dilated pupils. If you're withdrawing from them, you get a very chilled out, cool, calm personality. If you're on opioids, you get depressed and anxious. If you often opioid streak pains, you get aches when you're coming off them. Um, withdrawal doesn't kill the patient. But it doesn't mean that it's, it's really, really uncomfortable and very, almost painful. It's not nice. And then two people don't continue using drugs because they like drugs, particularly opioids, they keep using to stop themselves withdrawing. That's the cycle people get into. It's not because, oh, I really like drugs. So I'm going to keep using drugs. It's, I don't want to get sick and I think people don't understand that sometimes. So these are the long term. Um, so basically you withdraw them, you can build them down, um, with, you know, giving them small amounts of opioids at certain intervals and then build them down to the point where they don't need them anymore. You can use Naltrexone. It's the best for opioids. Um, substitute methadone tends to be the best. But some people you won't be opioid free. If you're on methadone, you'll still be on opioids. It's just to stop you going and using like heroin or, or, um, or, you know, cocodamol buprenorphine again, lower risk of overdose than uh methadone. But on the daily visit isn't required methadone. You have to show up to the pharmacy and they have to watch you take it the mental health order. You don't need to know all of the mental health orders. So these are the forms I would note form one is the nearest patient relative. Two is a social worker, the approved social worker, three is GP and three and GP Brian that I remember it form five is junior doctor. So um I would say that's the one that's going to be most important to us. Form seven, junior doctor completes form after initial request for assessment. So form five and seven are the ones you really need to know about. Eight is the reg and then nine is the reg and 10 is a consultant and that's detaining for treatment for six months. 11 and 12 are to like extend that treatment and everything above 12 is about guardianship. Once you get out of a mental health facility, perinatal mental health, again, we're coming close to the end here and I get, we have M CTS to go through as well. But um, features of baby blues. So it's common 1st 3 to 7 days, all you need is reassurance. Having a baby is very, very upsetting to anyone. First of all, you have to give birth, which can either be by a section or by a vaginal delivery. Extremely painful either way. And you don't get that great pain relief. So then you're bringing home this thing, it is screaming, crying, you're in pain, you can't sleep. Of course, you're gonna be an just tearful and irritable. You just need reassurance that you get over it and then regular visit and follow up, make sure that you follow up with patients with baby blues, postnatal depression is goes on for about a month and, and it is a proper depression like we talked about at the start, you need, you need treatment, then sometimes people will actually need to be admitted for their postnatal depression, sertraline or paroxetine and CBT tend to be the way per psychosis that's disordered perceptions and delusions. It's, it's a true psychosis. That person needs to be admitted to a mother and baby unit. Unfortunately, we don't actually have any operational mother and baby units in Northern Ireland. But if you were in the UK, it would be a mother and baby unit. So the rest of the UK, I think they're building one in the city. But I don't know if I don't think it's open yet, but um, it's to separate the mother and baby can sometimes actually worsen the psychosis and can really affect the bond that a mother and child have. So, only separate a mother and child if absolutely necessary. So, unexplained physical symptomatology, this is something you'll get on your MC QS a lot. And functional neuron disorder is conversion disorder. It's these neurological symptoms, they're occasionally inconsistent like some, somebody with sudden onset blindness but walks without bumping into anything cannot be explained by any known physical illness or mental health issue. Frequently associated with psychologic stress. The thing is, is that the way this was explained to me, which I think is very good was that if I hit my laptop with a baseball bat and put it in a CT scanner, I'll see damage. But if I upload a computer virus to my laptop and put it into a CT scanner, I'm not going to see anything. This is a problem with the software, not the hardware. If that makes sense. Malingering is the intentional production or exaggeration of symptoms. Normally for financial compensation, somatization is multiple chronic physical complaints, often including abdominal or back pain, persist for at least two years and are accompanied by refusal to accept reassurance. So people, you'll scan these people or do bloods and you'll be like, everything's fine and they'll be like, no, it's not. No, it's not and they refuse to accept it no matter how many times off dissociation or it's very famously known as dissociative identity disorder. But dissociation is much more common than dissociative identity disorder and dissociation separating off certain memories from the normal consciousness. So you can get that f state or stupor or amnesia factors disorder is Munchhausen Syndrome or Munchhausen Syndrome by proxy. Everybody will be aware that Gypsy Rose Blanchard case. She's now out of prison. She had her boyfriend murder her mother because her mother was faking loads of symptoms and making her intentionally unwell to get, you know, emotional support. Um illness, anxiety disorder, hypochondria, persistent belief in the presence of an underlying serious disease, eg cancer, they'll have a disease that they say patient again refuses to accept reassurance or negative test results. So the SOMA will say that there is a problem, illness, anxiety disorder will go, I have this and you don't believe me. So autism is impaired social communication and direction and it's a spectrum disease as well. So there's lots of different forms, there's high functioning and low functioning. Um These people tend to play alone. So if you're going through your pe's milestones, parallel play is normal up until a certain age. But after a certain age, it's not fail to regulate social interaction, nonverbal cues like I ideas facial expression and gestures, failure to form, maintain appropriate relationships and become socially isolated. So they might repeat certain behaviors like people would call it stimming where they repeat certain like you know, maybe like flapping the hands or touching the chest or squeezing something or rubbing their fingers and they, they can be quite inflexible um to nonfunctional routines. So they can be quite set in their ways again. Could be crossing over with CPD. Children noted to have particular ways about going around everyday activities. Like I have to use the green spoon, mummy to eat my vegetables and I have to use the blue spoon to eat my fish. So ASD is, it's often associated with intellectual impairment or language impairment, but you can get very high functioning people with autism who heads of universities, it can be comorbid with AD HD and epilepsy and it's associated with a higher head circumference to brain volume ratio. I only found that out when I was researching for this. So managing autism, this is a very long list. I'm not going to take you through it all. A lot of managing autism is going to be social and you know, just making sure that the family is ok that the child is safe and healthy and medicating where necessary, not where like not where wanted people will say, oh, I can't cope with this or you know, the child is, you know, I can't manage them, but actually they can manage. The child is not doing anything that's going to be a risk to themselves or others. It's just, it's hard to have a child with autism and like it it's, it's hard, no matter how, you know, heavy their symptom burden is, it's very difficult impairment. But the, essentially the advice is do not medicate, if not necessary. You need to medicate against severe anxieties, severe depressions aggression. Some Children with autism because they can't recognize facial symptoms, they can't recognize somebody who's in pain. So there have been cases where a child who has severe autism who has become aggressive can actually kill their caregiver because they can't recognize that the person's begging them to stop and that if they keep going, they'll hurt them even worse. And that, that's, that's a, a facet of the condition, not of the person and then me infinity is for AD HD. But often it's comorbid a lot of this is just family support and support groups as well. Ad HD is inattention and hyperactivity. The first time is parenting classes and family therapy. If you have done your rotation, you have probably seen, there's a lot of people who come in and say, I think my child has adhd and there is a line between my child is behaving in a way that is not easy for me to manage. An adhd adhd is the inattention hyperactivity. Here's a list of ways in which adhd can affect people. They can become aggressive, they can become, you know, frustrated, they can need to get out, they need to fidget, they need to go beyond the go, they're easily distracted. Whereas a child who might just have a little bit, a lot of energy because they're a child does not have AD HD. It has to be inattention hyperactivity. There is also a bit of a crossover with EE PD or a lot of adults because there is, there is now this growing sort of online awareness of AD HD in adult ad HD where um people will say I have AD HD and you know, I'm an adult and this is how it affects me. And they'll talk about emotional dysregulation, which can be a part of AD HD can also be a part of a personality disorder. So always when you're exploring AD HD, explore mood as well because they can mimic each other. Metadate is the thing to use in Children. You only use it for six week trials though, it's a stimulant of uh dopamine and norepinephrine. Um Side effects are, yeah, side effects aren't great. You have to monitor weight and heighten these Children and then you can switch between, I'm not even gonna try and say this Dexa I can't, no, I'm not gonna do it. And first line options, switching between simmons a cardiotoxic, just remember that. So it's not great to be on the long term. Sorry, that's a whistle stop tour through psychiatry as like that's not even everything as well. There's so much in psychiatry, but that the, the slide can be used as notes, which is what I would hope you do. These are the past ay that have come up on psychiatry and I've tried to update them as much as I can. The numbers in the thing or the years that they came up. Um, so I've put a couple in the, the mental health order does come up. So, do know it. Um, counseling, as you can see, quite common. Borderline personality disorder, again, quite common. And suicide risk assessment is really, really common. I'd I'd be able to suicide risk assess. So CQ si don't care if you guys want to unmute or put it in the chat, but we'll fire through these. So, an 82 year old woman is brought to the clinic by her daughter who's concerned about her mother's deteriorating memory over the past six months. Daughter reports that her mother forgets recent conversations, struggles to recall the names of close family members and often appears disorientated. On further question. The woman reveals feelings of hopelessness, insomnia and a recent loss of interest in her hobbies. She denies having any focal neurological deficits. What's the most likely diagnosis? And either put it in the chat or somebody on mute because I don't want to sit here in silence for just OK. Thank you. D so. 00, hi. Um Pseudodementia. Uh Do we all agree? Does anyone else have an opinion? Let's see here a or the saying? A OK. Right. It is D so um if you read through this, she is ticking some boxes in the dementia and, you know, her age and in the dementia criteria and her age would sort of lean you towards dementia. The thing that really tips it in is feelings of hopelessness, that's depression. You don't really get feelings of hopelessness and dementia, insomnia. Do you remember? I gave you that list of other symptoms, recent loss of interest in her hobbies, that's anhedonia and no focal neurological deficit. So that rules out frontotemporal dementia immediately Alzheimer's ok. Maybe normal aging, definitely not vascular dementia. Again, her problems would be more global. Um Oh, Catherine, can I come back to your question in just a wee bit? Um because I'll take you through that because it came up the year before me. So a 27 year old lady Britney is brought by her husband to the general practitioner. She's been diagnosed with bipolar two years ago, which has been well controlled on met him. Britney's husband is concerned that over the last week Britney has been acting differently. She reports that she's been very energetic despite only sleeping for two hours each night and has become more talkative and confident. Britney is still attending work and denies any psychotic symptoms or suicidal ideation. Which of the following is the most appropriate management for Britney and give me an answer quickly because I want to answer Catherine's question. Hey, thank you, Sarah. Anybody else can jump in. I'd like to get a mix of answers. And Georgia. Oh, sorry, you sent that to me directly. Sorry. Um Right. Yes. The answer is a refer Britney routinely between the mental health team. That's hypomania. That's very stereotypical of hypomania. So, um I'd met Britney probably wouldn't be. Also, you've noticed here, I've used section two of the Mental Health Act. We don't use the Mental Health Act. So if it says Mental Health Act, you can rule it out immediately. Question three. A 32 old woman presents the with her husband reporting a sudden onset of leg paralysis and difficulty speaking, that has developed over the past two hours, she denies any recent trauma or illness. And this is the first time she's experienced these symptoms on examination. She is unable to dorsi flex her feet while supine but can walk on her toes. She also mentions that um significant anxiety related to an impending job deadline and her role as a graphic designer. Her medical history includes asthma, manage counseling and anxiety. I don't know how sorry. I didn't write this question. I don't know how asthma has managed through counseling. Right? Great. Someone has given me the answer. Thank you. Yeah, conversion disorder. Perfect. That's quite typical. They also will tend to make these um questions about women. Um I don't know why but um yeah, a lot of them are female best. So a 23 year old woman who works as a computer programmer presents the clinic with a request for a referral to psychiatry. She had longstanding preference for solitary activities and displays and lack of interest in performing close relationships, which has been apparent since her early teens. Despite performing well at work, she interacts minimally with others and demonstrates limited emotional response. When giving feed. When giving feedback, there is no history of odd or magical thinking, unusual behaviors, hallucinations or significant periods of mood elation or depression. Let's see. Ok, I got one on for Catherine, Georgia and Sarah. So this is the schizoid like I'm saying the void. So lack of interest in forming close relationships interact, minimally demonstrate limited emotional responses. They're an emotional void. She doesn't really care about anybody else, not in a nasty way or a cruel way. She just doesn't take that in. So that's a schizoid. So you're a doctor in a medical ward. You receive a bleep from a nurse who has been an extremely agitated patient. As you're right, the patient has become aggressive and is attempting to hit a healthcare assistant. You try to calm the patient down and deescalate the situation, but you're unsuccessfully decide the patient will need rapid tran you request haloperidol to be prepared with to continue to try and calm the patient down. What medication is important to also have prepared in case the patient suffers and a dystonic reaction. Uh Georgia. Thank you anybody else. OK. Thank you. Yes, the answer is a procyclidine. So dystonic reaction, you treat procyclidine, right? Thank you guys. I'm going to go back because um Catherine had a question there, what type of station comes up on the m and my friends have decided last year they had a station where you were talking to a patient relative and the relative was asking um the relative was asking about the um you know, why are you detaining them? And you had to explain the mental health order and then they were asking questions like, well, if this happens again, how do I get them admitted? So does that make sense, Catherine? Sorry. So being able to explain it in patient friendly terms? Yeah, it does. So would you have to like, do you have to, would they give you the mental health order um on a sheet or do you have to know all of the sort of forms off by heart? I would know them off by heart because there's no guarantee that they'll give you a form. Um But I would learn off to see that list. I've given you if you do the feedback at the end. Um I would um go and go through that and just learn those off because those are the important ones. The other ones that I've not listed there are like nursing assessments which you don't need to know about anyway, because these aren't nurses. So I see for, you know, the way you said that you would like, they would ask who or how do I fill it. So would you be like, oh you can fill out a form one? Yeah. And then who did he give that to? So you can you essentially contact your healthcare professional or you know, you would ring because you need two people to admit a patient. So you either need a close family relative and the GP or a close family relative and the approved social worker or the approved social worker and the GP. All right. OK. OK. And the way that they prefer to do it is the approved social worker and the GP, because the person, the close family member, when that person gets out of the psych unit, that's going to be their main support. And if they have had them admitted that can really like degrade the relationship and there can be no trust anymore because I mean, imagine if your mom or dad or brother or sister had you detained it, it doesn't go down well in families, it causes arguments, right? OK. I've got another question here. What's the best resource for psych stuff past me? Shit. Uh Or um personally, if you're looking for psych theory, um I, the DSM and the ICD are where you'll get your definitions in terms of questions passed is very repetitive. I don't mind. Um Ques um but that's just my learning style. Um Tricky cyclist is good as well. It's um quite good for, you know, have another very specific schizophrenia history versus bipolar. Um, and it's just tricky cyclist as in, like tricky as in difficult and cyclist as in a cyclist. I don't know why they called it that. Uh, I think it's an old school term for psychiatrist. Um, I like metics as well. G medics has a lot of, um, like they, the interactive, a checklist which I quite like and they have it for the mental health order or not, the mental health order, the um mental state exam, which I find quite good. Um Depends on what what you're looking for in fairness to not in any way helpful. Yeah, it is. Thanks and just remember all of that these messages are um kept. So we just watch your language. Um Is there anything else anybody have any more questions? No, I'm going to just stop sharing here and I'm going to put a feedback link in the chat. If you can all give it a go and one second, I'll get it out of my email. Apologies. So you are seeing my email but at this point in the year, who cares? Already passed the exams? All right. Um And if you get, if you um sorry, I better send it to everybody. OK. Meeting group chat. Oh, thank you, Shana. Um Oh, everyone's saying. Thanks so lovely, right. Um Fill this out and then you get a copy of the slides. These slides have designed them to be good for notes. Um If anybody has any more questions or anything they're worried about? Um, sorry, did I put my email at the end of the slide? Probably not. Um, but yeah, you can send me an email and ask me anything you need. So, um, I'll just leave that there. Anyone of any last questions I can see everybody running off. Sorry, psych is a very lengthy subject. So, but that's everything you'd need. Right. Bye, guys. Enjoy your evenings.