Computer generated transcript

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

Cool, we are live and we've got a nice group that joined us. So welcome uh to everyone that's joined us for our first Psychiatry webinar. Um the Mind uh Psychiatry series. I'm joined by Dr Anna Borisova, who is part of the Thinking Mind Podcast. And they're uh team have very kindly offered to collaborate with us on a series of webinars coming up. So definitely stay tuned for what is to come as well. We'll be covering um some of the kind of more um different topics of psychiatry, not just kind of core principles, but also about team dynamics, leadership, the Mental Health Act. Lots of things that are very applicable to practice throughout every specialty, not just a psychiatry rotation uh is our aim. So I will hand things over to our speaker. Feel free to ask any questions during and will uh make this as interactive as possible. Hello, everyone. So my name is Anya, I'm a Psychiatry CT three or S T three working in South London. I have some research interests. Uh So, hence my official title is an academic clinical fellow, but for all intensive purposes, I'm someone who's been training in psychiatry for the last few years, I would at the moment, all I can see is myself. So I would love to get some sense of who's in the room. And I don't know if people want to post in the chat just to kind of give me some names where you're working at the moment or what level of training you're at. If you've had any psychiatry experience, feel free to answer any, uh or none of those questions, but even just some sense of, you know, to say what training level people are at and that will also verify that everyone can see and hearing me. Okay. Um So I'll give you some time to do that and I'll get started with what my aims for today are. So I would like to talk through three cases. Um I'm hoping that we will have time to go through all three. They are common things that you might see either working in psychiatry, but also the reason why I've picked them is that they will be common things that you might see if you're working in a any general medicine, uh just a general hospital at, at whatever level you might be and brilliant starting to see some names coming through. So that's really nice. Um Be my aim is to do this in a way where you think about why you need to know what you need to know. Um Give you some tips on how to run your consultations and where to get more information. If you find this interesting, I can see that we've got a lot of people who are at the student stage, which is really nice. Um You may find that the level of this and the way that I've pitched, this is quite different to anything that you've done at medical school. I hope that means that it will, sorry, medical school, nursing school at any other education training. What I'm hoping that means is that it is interesting and that you, you learn something, what whatever level you're at. It may also mean that I'm saying things that you haven't heard of or that don't make sense. Please feel free to either interrupt me with uh with speaking or to post something in the chat if I miss it in the chat. Um, Isabel can, can highlight that to me. Um So the principle for this that I'm working off is that you are working at the level of a psychiatry trainee. So you're potentially someone who's done your foundation training or that you're someone who's joining a psychiatry team as the foundation doctor. Now, the thing that I didn't include in this is that it will also be very relevant to anyone who's thinking about mental health, nursing uh in Psychiatry. We've got very, um what's the word? I guess the roles are quite blended in a way in terms of nurses and doctors, particularly in a liaison setting will do very similar things. Really. The main extra thing that the doctor will be doing is prescribing and the training has covered it from slightly different perspectives as well. But again, hopefully, if you're in nursing training that this will feel quite relevant, um I want you to be thinking what is the purpose of this consultation? And I think this is the thing that is really transferable to any clinical situation whenever you're going into a patient encounter, think about what, what is the purpose. And I want to try and use the word purpose rather than agenda purpose gives you some breath in the way that you run it. So you're not necessarily going in with a list of questions that you're trying to get through. Uh and purpose hopefully means that you go into the consultation a bit more present, paying attention to the person and responding to the to the cues that they're giving you. Yeah, as I say, because of the way that I'm pitching this, there'll be some assumption that you've got experience in general history, taking general examination, how to make a management plan. You may not. And that's okay. I think this will still make sense even if those things are new. It's just that I won't be covering step by step how we do those things because I think they will come up and be taught just in general training. Um Awesome, really nice to meet uh those of you who are chatting. So I'll jump straight into a case. So you are working nanny as a member of the psychiatry team. And you're called down to see a 24 year old woman who's been brought to Anne by the police because she was running I/O of traffic. She's been brought on a section 136 and I will cover what that means to a any you get the police hand over and what they tell you is that they responded to some calls from the public. This lady didn't make sense. Her knees were cut up. She wasn't violent, she was searched by the police. They didn't find anything. They also didn't find any information as to who she was. She seemed confused and it took a long time for them to get her details. She couldn't seem to remember all of these cases are not really people, but they are based on amalgamation of people that I've seen over the course of my training. So they are uh they're not in any way identifiable, but they are situations that that do come up in clinical practice. So the first question that you might be asking in a psychiatric case presentation was this person come been brought to any. Now, the first bit of knowledge that I think is important to have here is what a section 136 is, although if anyone has ideas as to why she's in A and E straight off feel free to post in the chat straight away. Does anyone know what a section 13 sixes? And again, I'll pause for a minute so you can send it in the chat and feel free to get it wrong. But just say, you know, I have a feeling this is roughly what a section 136 means. Yes, Maria Pavel. Nice. Perfect. So I will come to what you've said. Let me answer what a section 136 is first in case that yes. Exactly. Thank you, Mindy. So police, if they are concerned about that, somebody might be experiencing mental health difficulties, they can take someone from that public place to a place of safety. Um And thank you. Yeah, exactly, Paul. So the and that is part of why is she in any? So exactly, as Pavel and Maria have said it looks like she might have some injuries. So she needs to have that assessed. Um There may a place of safety can be something like a and a it is often and ideally would be a mental health based place of safety. But the reality in the UK is that they often don't have space so often somebody will be taken to A and E because there isn't space somewhere else, even if there isn't necessarily a concern over their physical health. And the other reason is that we've got somebody, a young person with a chain with, with a new onset of mental disturbance. We want to have a think if there is something physical that might be going on contributing to that. So um the term that you might hear being talked about is of medical clearance. That's what I want to touch on here. First of all, the a any medical clearance I think is often said with a bit of a bit, either bit of confusion or a bit of an eye roll, bit of frustration from the people who say it or who receive this question in my mind. And in my experience when it works well, what it should be is a check for any injuries that you know, could be an emergency by someone who's qualified to do that. As in somebody who's got trained in emergency, physical health, it's also a reasonable consideration of physical causes for a change in someone's mental status. So there are lots of things that can cause someone to be acting strangely that aren't primarily psychiatric. And what I mean by that is that there is something that is very clearly reversible and that it is important to treat urgently in order to prevent a further deterioration. So for instance, an infection that if you don't treat, you know, somebody could potentially go into sepsis or head injury or trauma. Again, that if you send someone to a hospital that doesn't have physical health provision could potentially significantly deteriorate. So some of these things are a lot harder to think about us in a psychiatric ward in the UK, because I know we've got some people from abroad in the UK. Your mental and physical health care is very split. Unfortunately, that is problematic for certain reasons. For instance, like here where you're going to struggle to get investigations done in a psychiatric ward that you could get done in a physical health hospital. Um What the medical clearance again in inverted commas should be though is collaborative. So particularly if somebody's going to be in any for a while, there is no reason whilst these things are being considered, particularly if somebody needs some kind of psychiatric input. So for instance, the management of them being aggressive, restless distressed, why a psychiatrist can't also be involved alongside the physical health team in assessing that person and thinking about what could be helpful to them. And so what I'm trying to say is that it shouldn't be a battle over who takes responsibility for the patient. It shouldn't be an opportunity for someone to just sort of sign their name and dismiss that this isn't, you know, it's obviously psychiatric. We don't need to think about it beyond that, a collaborative working that has the patient at its core and is thinking about what is best for that patient is what I've often seen the medical clearance to be and, and that's when it works really well. What is your purpose? And I apologize, some of my animations haven't come through here. But I would argue here that your purpose in this assessment is differentials. So when you're seeing somebody, any in a, any uh you are trying to think about, are they where, where and who does this person need to be looked after? And that means do they need to be looked after in hospital? Do they, can they, are they safe to go home? And if they're safe to go home, what kind of follow up they need or if they're in hospital, you know, simply what kind of follow up, which, which team needs to be thinking about this person further and the way that you identify that and figure out what questions are you going to be asking is three your differentials. So having an idea of your differentials in your head, even before you go and see the person means that you can tailor your questions to them. Now, before I go to the next slide, are there any differentials that are coming into people's minds based on the discussion that we've had so far? Okay. Lovely Millet Maria with delirium. Very nice. Uh huh. No, we can do reactions. Beautiful. Okay, thanks dot Hello. I'll pause for a couple more seconds. If anyone has any other thoughts at this point, there's really, really no way to be wrong because all we know is uh what was on the previous, uh all we know is what was here. So somebody who seems confused seems to be a bit slow to speak has been running out I/O of cars and the fact that it's a psychiatric teaching session. So that might take you further. Um Beautiful. Yes. Thank you, Pavel Confusion, Hisham. Anti M M E O N M D A R. So I'm going to guess that's uh so an autoimmune encephalitis with a, with auto antibodies against NMDA receptors. Head trauma PTSD. Yes. So something to do with a traumatic experience where somebody's where she might be having a reaction to it. Uh Thinking about drug as a cause and then we've got some psychiatric questions as well. So is she experiencing an episode of mania? Is this actually intoxication? So, not necessarily something that's occurred post substance use, but is she, is she intoxicated? And that's why she's behaving strangely. Thank you so much. Everyone that was beautiful. And I think that's kind of all the things that I've put on. The only extra one that I've included is post ictal. So, and, and that's, is somebody who's had a um somebody who's had an epileptic seizure and might have an episode of confusion or just being not quite themselves afterwards. Um And then the first episode psychosis there as well, which potentially would be encompassed in mania. Probably you're saying possible homelessness, I am interested in where your thought is going. So if you want to write out a sort of a bit of a blurb as to your thought process, please do and then, and then we can come to it as we discuss. Um, my next question is going to be, what do you want to know? And so how will possibly as you're writing your things? You can say that I've got some very, I guess key questions in the, in the history that I think are important. All of the history is important. But again, I'm just giving you a bit of a snapshot of this case. So any questions that people have in mind that you would want to be asking that are going to be helping you push these diagnoses, either lower down or higher up because that's what your history is for. So, whilst I've got you thinking, what I'm going to do is show you the questions. But then I want us to think together about why the questions are important. So if you've got questions in your mind, you haven't had a chance to send yet, then have a think about what questions are important. So you're going to be wanting to try and ascertain when all of this started, you know how she's been running it out of traffic for days and only just got the police only just got called has has her strange behavior been going on for a few days? Was there a trigger? So I think it was Maria who asked about who was thinking about trauma, but specifically thinking about drugs either immediately before or longer term, any illness, any injury. Um I've now got them. Yes. Okay. Um, any injuries, any arguments or stressful events, what was her mental health history before today? And what is you may not necessarily be asking, but having to think about what the risk is. And so the things that people posting in the chat are exactly on board with that. Now, why are these things important to know? And I will talk through this. So when did this start? Because if it's a psychosis, there will often have been something going on for a few days or weeks, but not always. Um But again, you're like you, if you ever go to lectures by neurologists, they're always very keen on knowing, you know, what is the onset? Was there something that happened like out of the blue? Straight from God? So that gives you some sense of what your diagnosis is going to be exploring with the person for triggers or and trigger is obviously the word that you're going to have in your mind. But with the person, you're gonna be asking what was going on earlier today and that's going to help you narrow down your differential. So drugs, you're most common things that you're going to be looking out for and asking for specifically are cocaine, cannabis, methamphetamine, but it could be anything alcohol can uh obviously lead people to have an acute disturbance or a change in that mental state. In terms of illness. Again, it's broad. So you might be having, you might have somebody with a chronic illness or you might have somebody who's got a cancer diagnosis that you need to know about. And again, that's going to push you to think in slightly different ways, picking up for a history of fevers. So I think somebody mentioned about acute illness or this being um like an autoimmune, Katha litis fevers is going to be an important thing to pick up if. So, um thinking the reason why you want to know what, what the mental health history before today is that in a different age group, you're much less likely to see psychosis uh as, as the reason and something like delirium would be much more likely to, to be the reason why somebody has an acute change in their behavior. And knowing about risk is the bit that psychiatrists will often really focus on and why it's important is it will really dictate your management and the kinds of risks that you'll be thinking about in psychosis are suicide and self harm. Those suicide risk is increased a lot by psychosis. Um You want to think about is that person eating, drinking, how they're looking after themselves. And this will be relevant to somebody with a delirium. You know, if it's a mild case of a delirium, they might be able to go home. But actually, if they're really disturbed, if they think that the food is poisoned. And this is something that somebody might experience in the delirium, not just in a psychosis, uh, if they're really distracted, if they're struggling to make decisions, they might not be safe to go home, especially if, for instance, they live alone. And so you need to know those things when you're making your plan, the thing that's maybe thought about a bit, uh, less because it's maybe a bit of, less of a headline, but also just is reputation risk. So, has somebody got access to their phone? Um, uh, let me come back to that question. Um, the, so has somebody got access to their phone? Are they sending strange messages posting strange things that they wouldn't necessarily normally post? But because they touch on reality has been changed by their illness, they suddenly think those things are reasonable and then really important to think about risk to others again and anything like, uh, anything where somebody's got an acute disturbance. Um, the think about, are they hearing voices that are telling them to do anything? Are they thinking that the world has changed in some way that they need to take action against it and then thinking about risk from others as well? So who is around them? Are they people who they are safe with? Um, there is when it comes to things like psychosis, which can make somebody quite vulnerable but also affect their thinking. The thing to have in your mind is that there can be a tricky area around sexual assault abuse that these patient's are really high risk for experiencing a sexual assault and abuse. They are sometimes ignored when they report these things because people think that it's just to do with their mental state because they, they have a delusion. So have it in your mind and follow things up if there's suspicion because people who have a have an acute disturbance in how they're acting are vulnerable. Um Let me pause there. Um I might come back to questions at the end of this case. So have it in mind, but I'll come back. Although Dr Addy, I think I may not directly cover this as so maybe we'll speak about it if there's time at the end. Um And Pavel. Yes, absolutely. So I guess what you're pointing to there is thinking about somebody who is, who something either like a factitious disorder or potentially malingering or whether it's some kind of secondary gain in the way the person is presenting. Um the, the thing that we work off is that it is it is possible but the majority of our patient's do not choose to or honestly making a conscious choice to act in the way that they are, it is something to have in your mind because it can happen, but probably lower down in your mind mainly because it is uh it's such a tricky area and you're going to find it really hard to know whether you know or not. Uh, and erring on the side of almost giving people the benefit of the doubt. It's kind of safest for your rapport with them and for your relationship with them. But it's an important thing to bear in mind. Um So the next question that I've got is, and this is what happened or often happens to me when I speak to patients like this is that you try to take your history and you get nothing else. And I saw somebody earlier on in the chat say, does she have anyone who you can contact to get a collateral? And that's what I really want to highlight with this slide is that you may have to do quite a bit of detective work when you're encountering patient's like this either as their nurses, their doctor is there junior doctor. So think broad about where you can get information from. Great. If you can speak to someone who knows them when it comes to things like drugs, you can assess for them with some tests that can be available any sometimes aren't and sometimes you have to wait until someone to get to psychiatric wards. And this is my cat coming in for the ride. Um You can obviously do get quite a lot from your examination. Um You can also get some things that particularly in London, but I imagine also around other parts of the country as the NHS gets increasingly electronic from your electronic GP records. So don't under uh, don't underestimate how beneficial these things can be. So, what do you want to do next? Oh, I'm sorry, Maria. Yes. Um, that's, I've tried to avoid abbreviations and that's my bad next of kin. So family, friend, somebody who would know her and once you've done your history, what are you going to be thinking about doing next? And for the eagle eyed amongst you, my screen flashed on to that slide before, but what are going to be your next steps? Once you found out some of the information in the history, how might you be managing this person? Yeah, exactly. So, thinking about clinical investigations and that's where in A and E working with your A and E colleagues because if you're the psychiatrist, you might not be able to actually arrange or organize at those getting some basic examination in. Exactly. Yeah, exactly. So, thinking about what can be due to treat or improve and I would think about within that, you're thinking about how to manage any acute risk. So before there was maybe some signs that her movement or her motor Axion was increased if she was running it out of traffic, if she seemed to be confused. So you might be thinking about how do I contain this person in any department? Do I need to think about her having a 1 to 1 nurse or 1 to 1 healthcare assistant with her who can redirect her, who can speak to her, just try and explain to her what's going on even if it seems like she can't necessarily understand giving her that, using that what we call verbal de escalation if that doesn't work thinking about if you need to use any medication, to give any sedation, so to get somebody calmer and able to just be in the room where they need to be gathering all that information that we're thinking about and then giving things some time. So you may not be giving immediate treatments everywhere instantly. Uh, in psychiatry, sometimes we just watch and wait and that's dependent within psychosis. That is often what, what we will do probably, you're saying food and antibiotics. Absolutely. So, if you've got evidence of an infection, then 100% if it's not clear, if you haven't got evidence of that, I wouldn't necessarily, uh, but if you've got some suspicion that those are necessary, then yes. And then I thought I would talk through what a mental state for someone like this would look like or could look like. So the on the steps of a mental state, you initially look at someone's appearance and behavior, you might find that someone like this is quite perplexed and what that means is that they sort of a bit puzzled. A bit bewildered, maybe a little bit slow to speak to you. She was reasonably happy to speak to me in that she came with me to the interview room. Uh, someone like this would seem to be trying to speak to me. Um, but she didn't actually seem to be able to share any information. And I wondered when I spoke to people like this, you know, are they distressed as this or actually, are they having some thought disorder? So they're not completely understanding what I'm saying or not completely able to understand their thoughts. Um, she spoke in a way that I could hear her. Uh but the rate of it was quite stop stopped. She seemed quite label and affect. And what I mean by that is that she would go from laughing too saying then appearing quite distressed and tearful within the space of a consultation. Mhm Her thoughts appeared quite disordered to the point of derailment. And what again, what I meant by that is that it's really actually bordering on the incoherent. So really quite hard to make sense of what the person is saying and it can be nice in your thoughts, section of a mental state to include um to include some words of what the person is saying or to really try and give the person reading it a sense of what the person was like in terms of any abnormal perceptions, hallucinations. I didn't see her to be responding to any auditory hallucinations. She didn't tell me that she was, I didn't see that she was experiencing any other hallucinations, but really, that's all I could comment on because actually accessing what she was experiencing because of the difficulty in communicating was, was difficult insight. You might often see labeled as just, you know, present or not present if you can, it can be nice to expand a little bit more. So, you know, it's simply put, we could say this person didn't have insight because we just struggled to communicate with her. But there was a sense that she could acknowledge something wasn't quite right. She would try to answer questions around what seemed to be going on, but just couldn't quite um she was willing to accept or consider medication. For instance, you know, if you offer the person the medication to take it, but you couldn't really discuss in terms of her cognition capacity, she was disorientated and again, you can only go off what they tell you. But if she couldn't tell me where she was, what was going on, couldn't engage with that kind of assessment. And then in terms of capacity and we'll talk about capacity a little bit more later. Um But she couldn't demonstrate that she could understand what I was saying, all that she could way up any of that information. So, Pavel you've suggested bipolar disorder and so what you, so what bipolar disorder means is you've got somebody who's having episodes of mania, at least one episode of mania. Often it's somebody who will have both mania and depression. What mania means is that you've got somebody who is really elevated in their mood and you can get that. I'm wondering if you're saying that because of ra mention of lability in the mental state. Uh You've got somebody who is often expressing ideas that are uh grandiose and what that means is, you know, they, they're really excited, they think they're really great. Well, they've got potentially even delusions that they're related to somebody famous or they're doing something really amazing. They often feel on top of the world. And I would argue they're generally a bit more excited than this person was presenting as. So my thoughts on this person assuming that you've done all your physical relevant, physical investigations and that you're not finding anything else in her collateral history is that it could well be our first episode. Psychosis. What does psychosis mean? So this is the didactic teaching bit. Um I've kept this fairly brief because I guess if you're interested, it's, there's lots of places where you can go and look up and read more. I think the important things that took me a while to get an answer to when I was earlier in my training is that psychosis is an umbrella term. So somebody with schizophrenia could have psychosis, somebody with depression could have psychosis as somebody with bipolar, could have psychosis, but somebody with bipolar or depression will not necessarily have psychosis symptoms. It relates to somebody having an experience of a change in their perception of reality. Uh So that might be through delusions. So changes in their thinking, hallucinations, experiencing um sensory things that aren't there disorganized thought and disorganized behavior which we could see with, with the case that I talked about. So where someone's thinking just doesn't quite make sense and negative symptoms, which means that somebody might come across as quite withdrawn. Um The people that tend to be affected and these are patterns, but they're not absolute, but generally in men from your teens to your mid twenties, people S R E mails and then in females again from teens, slightly later off until late twenties, the causes of psychosis can be really broad. So we may just not know. So it could be something that just arises as a primary psychosis, primary psychiatric presentation. But it can happen also not uncommonly secondary to substance use. And that will be uh so after somebody has used a substance is no longer intoxicated with that substance, but in the hours or days after has psychosis symptoms, it can be secondary to in other conditions. So you, you may well get psychosis symptoms if you have Parkinson's uh autoimmune encephalitis, we've spoken about as of course, for psychosis can happen after epilepsy as well. And in terms of how you treat it, you've got a biopsychosocial approach. So the I guess the mainstay of medication treatment will be medications that block the dopamine blocker. And then you've, you've got types of therapy that can be used. So you can use CBT for psychosis when somebody particularly is in the um is not necessarily the most acute stages of the illness, but also you will have a psychologically minded approach to working with them. And what that means is you've got some sense of what it is that they might be going through and you're using that information in how you work with them and then your social input is really important. So that person is going to need a lot of support getting their family on board, having regular follow up in the community thinking about what their housing like, what are their bills like? What other issues are there that could be contributing to that person not getting well and I am aware of time running away. So let me go a little bit faster, but hopefully I've got you all involved and at this point now, feel free to just jump in with ideas into the chat. I may pull out some of them. I may not. Um But what I hope you've taken away a little bit from this case is what a section 136 is. Some of the sections of what a mental state exam is. And then thinking about psychosis or not narrowing down too soon. So when someone's in a and E if it's the first time that they've come in with a behavioral disturbance, they need some thinking about that. Doesn't mean they necessarily need investigations. CT scans, MRI scans, but for some people, those will be relevant and necessary. And it may not be a classic presentation in the mental state. So the mental state that I presented, we didn't, couldn't obviously tell if this person had hallucinations. We couldn't obviously tell if they had delusions. Uh But actually, there were things there that in the, again, as I say, in the absence of any other obvious cause is point us to that there's potentially could be a psychosis. And then we watch and we wait, we don't necessarily have a diagnosis to give him the first hour or the first day. But we say that, you know, this person needs some treatment in hospital and we watch and we see how it develops. Next case. I hope you are all still with me and feeling energetic. Um So the theme is going to be of self harm. So we've got a 24 year old man. He's been brought by his partner. He's called, oh, I've got the age wrong. 34 sorry. Um He's coming with his partner. He called a crisis phone line to say that he was feeling suicidal. What you learned from the person who triaged him is that he's open to his G P. He's not under any psychiatric teams. He's got a diagnosis of E U P D made several years whilst under a home treatment team, he has a history of self harm and taking overdoses in the past, but he's not on any medication. So what really, what this is telling you is that it's somebody who's actually had fairly minimal psychiatric input, who has a diagnosis of E U P D stands for emotionally unstable personality disorder. Um It can also can also be called borderline personality disorder. It is a highly imperfect and controversial diagnosis for very good reason. Um It is nonetheless still something that you're very likely to see in people's notes. Um And, and so that's why I include it here. And again, this is a sort of fictional case based on things that will come in often. And actually, it's a case that I'm grateful to some colleagues of mine who ransom teaching. And um I wrote this case for the, your purpose. There is a, as the genius psychiatrist or the uh psychiatric liaison nurse who's doing this assessment is to be thinking, can he go home or not? And if he can go home, what does he need in order to make going home safe? So you're not necessarily going to be making a diagnosis. And that's why I'm not saying differentials at this point, you're not going to be trying to reach a diagnosis or sort of do a really beautiful formulation on someone who's come in really distressed in crisis and in the environment of a any that's probably something that you want to be doing later on. Not follow up when you've got more time to spend with him. Um But you do want to figure out what is the care that he needs right now, the things that you will ask and I'm including some other types of questions that I would potentially be using is to start really broad. So you're broadly, you're doing a risk assessment. Uh And that's where your history is going to be focused. So understand about what it is, that's happened and structuring that by thinking about what was going on before the self harm, thinking about trying to get an understanding of what they were thinking during the self harm if at all or what the almost purpose of the self harm was if they can think about that and where they're at now. So do they, are they currently thinking about any other self harm? Is there any other risk that you can identify? And then the rest of your history obviously is also really important. Why, why do you want to know all these various things? Why, what are you trying to find out in the rest of the history? Why are you going through what happened in so much detail? Why is this important in a risk assessment? I hope it's got you thinking, but I will skip ahead to what my thoughts are on this. You're trying to get a sense of what increases your sense of risk for this person. So what increases your sense that this person that might harm themselves again when they go home, if they go home or if this is a warning to a potential suit. So, given that they're saying that they're suicidal and their self harmed is just a warning that they're in a more severe mental state. And pavel you're asking also, is he a danger to others? And absolutely, that's something that is part of your risk assessment. Um, the key thing that I remember, I guess being impressed on me when I was training. Um and I think as and hopefully I can pass on to you is that generally people with mental illness are much more likely to be a victim um of violence rather than being perpetrators of violence. But again, in psychiatry, we do think about risk to self others and from of us for the very reason that there is sometimes a risk to other people. Paul you're saying is the trigger still there. Exactly. So you want to really get a sense of what and understand with the personal, what it is that was going on. And if that stressor is still really prominent, that's going to make it more likely that you need to be a bit more interventionalist. That's the right word in your approach to manage to treat it to looking after him. So these are the kinds of so formal risk assessments in terms of like using a form to assess someone's risk are really out of uh, common use or at least they ought to be, uh, or the sort of latest information and teaching that we've had from experts emphasise that there's just no evidence that if you use a tool you can, uh, you know, like a checkbox tool, you can predict what someone's level of risk is. Um, but there are factors that we know will increase, um, will increase someone's risk. And again, that doesn't mean that they give you any sense of certainty on the decision you're making. That doesn't mean that if someone scores five, rather than six, you have to do something different. Um It just, this is part of the art of the work and also while you're going to be involving a senior in discussing this case, but if somebody's got an untreated mental illness, um really anything that will increase your risk, if they've got any chronic physical illness, anything that causes them pain, any regular drug or alcohol use. And in part, that's because it points to potentially, there's somebody who's got some impulsivity, personality traits, but also because there might be using things that changes their level of impulsivity. So if you're more disinhibited, for instance, under the influence of alcohol, cocaine, your risk increases, um things that we can't necessarily do anything about. But if somebody is a single male and of an older age or younger age, if they're living alone, and that's pointing to if they're isolated, lonely and then any social stresses which again are really difficult to do anything about. But poverty, unemployment, if somebody's marginalized past risk is a really important predictor of future risk and family history of suicide is also really important predictor. And again, like I say, no certainty, but these are things that will help you in your assessment. If somebody is exhausted, if they've got really intense anxiety, these are things that you can do something about and that you can manage. So picking them up is important and what help to reduce your risk and self harm is an opportunity for intervention and uh some statistics to impress kind of why. And that whilst it can be easy, particularly, I think if you're working in a, in an a any department to become quite jaded to people who present with self harm, actually, that episode of self harm is really important to pay attention to in the same way that it will be if that person comes in again the next day or again in a week's time. Um just because somebody is regularly self harming doesn't mean that they are in any way less likely to die by suicide. Um Just because somebody has been saying that they feel suicidal for a long time again, doesn't mean that you pay any less attention to them. And this is very, very important. Um, people might use self harm or do self harm for lots of different reasons for some people. It is not necessarily done with lethal intent. It can be either an expression of distress or a way of managing distressing emotions. It can be a way to communicate, to influence or secure help or care. These things are not always conscious. So the person is not necessarily doing this with an awareness that this is what they are doing. But there is often in any Axion that is meaning if you think about it enough and it can be helpful to explore that meaning with the person. So um and somebody may self harm for different reasons. At different times, I will talk through some communication bits which I think are really helpful when you're working with people who, who have self harmed. And particularly also if you're working with people who might have an U P D diagnosis, which has come up for uh for reasons which has come up, which has been diagnosed because people think that they communicate in a way that's consistent with that diagnosis. Um For some people, it can be really hard to name the emotions that they feel. So it can be really hard to receive a question like why feeling suicide or what's making you suicidal? Just talking through the facts of what happened on the day might be easier for them. And then through that you might get a sense yourself, you might develop some hypotheses as to, you know, what distressing things were going on that day. And you know, no wonder, um, that they might be feeling really distressed, but they might not even be necessarily aware that they were feeling distressed. You know, for instance, their partner had a conversation with them about taking a job in a different city. So they might be moving away. Um, and the person just has no emotional response to that. But if you explore it with them, you might be able to talk it through and through talking it through, you can help relieve some of that distress. It's okay to acknowledge. If you think that you're sensing an emotion that they're not naming, but generally better to do that with curiosity rather than certainty, telling someone what you think they're feeling can feel a bit aggressive and also can feel a bit frightening to someone because if they don't know what they themselves are feeling somebody who's just guessing it, even if perfectly, you know, it's just a bit like how are you doing that? Whereas giving them some indication as to what your um sensing in them might be helpful. Um So an example of how you might do this, something that I think is important to know is that you may be the recipient of that person's frustration. So if you're rushing, if your bleep is going off, so you're having to go I/O of the consultation, they of course may feel quite frustrated and they might be angry towards you have in your mind that you might just be representing all of the things that have been frustrating in that person's day or even potentially week life in the past, it is never helpful to become irritated or argumentative back. Although again, you're human. So you might, um but it, if you can have an awareness of what emotions stirring up in you yourself and taking a breath, if you need a moment to just step out before you come back in the room, do do that. Uh, try and be kind of a calm presence even if you're not necessarily feeling that and, um, what and I'll come back as to why that's important. You may also feel like you just don't quite know what to do with the person and what you might be picking up is their own uncertainty or their own ambivalence. So they might not know what they want to do and make you feel like it's all really confusing, explore it. I think somebody talked about, you know, can we involve his partner or his friends? Yes, definitely. If the person consents involved, the people close to them that they want to be involved in the decision making an important one for a and e if you're discussing that person, be it with a senior or with your A and E colleagues, curtains aren't soundproof. And uh, if I guess, expect that anything that you say or think about how anything that you say could be taken by the or the person that you're talking about, if you wouldn't want to hear that being, uh, if you wouldn't want to hear sort of a family member or whatever being, um, discussed in that way, don't do it. Even if you think that you're somewhere that's completely private. Maria. Great question in terms of breaking consent. Yes. So with breaking consent, the rules, the rules are very clearly worded, but in reality, sometimes can feel quite difficult. The key thing really is if somebody doesn't want you to share with their family, explore why, explore if there is anything that they are happy to have shared. Um If it is important for a reason of safety and generally will be thinking about safety to that family member, um then you may well think about breaking confidentiality and not having consent to share information. That would not be a decision that you make alone and would always be a decision that you make with seniors and as a team. Um the, and if you are breaking confidentiality, then having the person, you know, explain to the person that you may have to do this, trying to have them on board every step of the way, you know, is there anything at all that there that they could work with you to find a way to do? Um So it's not a simple answer. And the learning points from this case are I hope you can take away and maybe also make you feel excited about potentially thinking about psychiatry as a training way. It is these are some of the skills of psychiatry. So it's, but there are things that will make you good at whatever part of medicine you're working because actually difficult conversations, difficult interactions, really uh the bread and butter of being a nurse, being a doctor, whatever kind of health professional you are working in a general hospital, having the skills to realize when you might be being pushed into feeling a certain way and they're not acting on that uh invaluable and having an understanding of why that patient will be pushing you to feel a certain way is what helps your brain in your own emotions. Now, we are going to be running out of time. So I'm going to um miss most of this and I guess in the last few minutes, I'll kind of leave it up to people. We could either have a quick talk about um capacity, we could have a quick talk about E C T um or we can just answer other questions that people have and I've put up some resources with some more information. Whilst people are thinking about questions, I think if you're interested in psychosis or how the NHS, how NHS journey works for somebody who's had psychosis. This uh psychiatry working podcast is phenomenal. Uh So please take a listen to it's on BBC radio four and obviously plugging the podcast that I work on, we've got conversations with experts in schizophrenia, psychosis, we've got things that kind of explore some of these disorders. Um and some of these questions in more depth. I'm not getting anything in the chat. And so Isabel feel free to interrupt me if you are. But I guess I might mention E C T just because this is something that potentially, particularly people are still in their nursing or medical training. You may not have come across very much and you might not really know what it is. But also you might find that um you have friends or family who expect you to know things because your training as a medical professional, E C T is a really important, effective and safe treatment for people who have a depression that has not got better with other treatments. It is also a treatment that is chosen by some patient's when they, you know, they know that they get repeated recurrent depression and they don't, they know that this is what works for them and this is what they want. It can also be used as a treatment and other psychiatric conditions, but depression is the most common. So you've got quite a bad press from the, well, even modern press um but also just from media from years gone by. And so if you're talking to someone about this, it's important to acknowledge any fears that they might have about it and find out what it is that they've heard what it is that might make them reluctant or concerned about it. It is a treatment that uses passes a small amount of electricity to cause a short seizure. It's conducted into a general anesthetic and so carry some of the risks that general anesthetics do. But it's very brief. So generally you are I/O of the, you know, from checking into leaving the recovery area probably in like an hour, the bit in which you're anesthetized and having the treatment 10 minutes, five minutes, this the seizure duration itself is 30 seconds, 45 seconds. Um And yes, there's lots of objective evidence for the clinical application effectiveness of the CT. Um It has been yeah, widely studied. Um and I guess a lot of clinical effectiveness that is reported as well. Um anecdotal as in my personal experience is the worst kind of evidence. But again, I can speak for that. Um it is something that is very helpful because it works quickly. So particularly if somebody is in a life threatening depression, I either not eating or drinking. Uh and that is starting to cause a risk of their life. The CT is something that will work quickly. Um It is also something that if somebody has a lot of medical co morbidities uh and reasons for why they might not be able, you might struggle to find another treatment that works for them. Actually CT can be quite good. So it's good in people who are elderly. Um and the key risks and problems is memory impairment. So again, something that's important to discuss with the person. Uh people will often have a lot of memory for, for instance, what was happening on that day and they may find that they don't have access to their previous memories as well. So longer term memory, generally, people find that that as they get better that comes back, but it is an important risk to acknowledge that it, they may not regain all of the memories that they have for some of the more recent but longer term events mechanism of Axion. Unfortunately, we don't know, as is the case for a lot of treatments both in psychiatry but also, you know, more generally in medicine. The example that I often give is of things like paracetamol, um, where we, we don't really know exactly how it is that it does all the things that it does and we know that the seizure, I guess the working theory is that it is to do with changing up something in the brain, sort of the word that you might hear being used or things like resetting a surge of electricity, neurotransmitters or whatever that in some way seems to change things up. But, but the honest answer is we don't know we are right on time. I'm very happy to take questions, but I'm also aware that people want to go and enjoy their evenings Yeah, I just had two things because I was just going through the questions that were, uh, and I think the two, there were two that were kind of not related to the kind of core bits that you've covered so well today, um, one was about the beers criteria which unless I'm mistaken is just the, it's the American criteria about stopping and starting medications in the elderly. But correct me if there is another one that I've mistaken it for, but I would say have a look at the stop start criteria, which I think is more, is the one that we more use here. We also have on the mind. The bleak page not to like plug my own articles shamelessly. But an article that myself in a, an old age, um psychiatry consultant wrote about the risk benefits of a lot of the kind of common psychiatric medications in the elderly and about deep prescribing. Um, and it also has a really good link to a lot of statistics from NHS England about the risks involved with, um, antipsychotic prescribing in the elderly. So it's quite interesting reading, but generally it's quite nuanced when you get to it. And different people, different clinicians have different opinions and it's very personalized to the patient. And then the second question was on which drugs cause SIADH problems with sodium. Um generally from looking at that. So that article does cover a bit of that as well. But generally lots of anti psychotics do. Lots of antidepressants do. There's a more host of drugs really. And again, it depends on the patient. So there's kind of not, there's not so much of a cici, there's a kind of few that are very renowned for it. So I think just have a look on the B N F or on any of the kind of medical go to and, and the Maudsley guideline will be good for psychiatric drugs. So it will, it has a section on hyponatremia unless I'm mistaken. But it, yeah, say, and I would from doing an endocrinology job currently, always get the advice of an endocrinologist. If you're in any doubt, if you see any medication that could be um could be the culprit, they're usually very happy to chat about. So Dean's um and we also have an article on the CT on the Psychiatry page as well if you want to read a bit just about the history um because and the procedure itself as well. Um And if you have an opportunity to taste today, I did that during my f one training if it's done on site. So I would recommend going to see it because I think that's quite, very useful. Um Just given, if you go off the kind of media description or the film descriptions, actually, in reality, it's a very, um quite a simple procedure actually is what I found and patient's do very well sitting having a cup of tea afterwards, at least in my experience, some of them. So, yeah. Um Yeah, thank you all for coming uh to our first uh webinar and thank you so much anya for your time. Uh You've given us and it's been a really informative session and I think what's been nice is it's moving more towards the reality of the job, which is someone who did uh psychiatry and F one. Uh It's definitely much more of this and you don't realize the independence, you're always very well supported in psychiatry, but you don't realize the independence of your own formulation of plans and your own impression of things and how it is very much a kind of group, multidisciplinary discussion than when you kind of start the job and you're always like a very valued member of the team. Um when you're starting cause I saw a few of you are starting jobs in it soon. So I have all the best with that for sure. Um And as I think what Isabel just said is really helpful advice for starting a rotation. And I think go in open minded, be kind, be respectful. You can't go far wrong with that. Um And anything more specific, I think, I think if you're starting with, with not much experience, just go in, you know, keen to learn and ask questions. Uh You might be asked for your opinion a lot. I remember being terrified and I'd just be like, I don't know, but it's like I just, just love to have a chat. So just say what comes to mind in a respectful way when you're talking about someone with your seniors and you'll learn a lot from that. Thank you so much, Isabel and thank you so much to everyone who's come and for participating in the chair that has been amazing. Um I am doing, I think the mental health Act session in a few weeks time. So come again, please feedback. How about how you would like that to be if you're coming or how this session could have been better? Um Because it's, it's just really, really helpful to have constructive criticism of how to improve. So please don't be afraid. I'm, I'm very resilient. Um and any future uh webinar topics as well, we're always open to suggestions. Oh, is that it? We'll say goodbye. Yeah. Thank you so much. Thanks everyone.