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Hi, everyone. I'm Chloe. I'm the psych. So president, I just wanna check you guys if you didn't mind just putting in the chat that you can all see and hear me and like see the slides. All right. That would be really helpful. Just I know I'm not talking to thinner. If anyone can just put in the chat to let me know that they can, you just see and hear me. All right, while we wait for people to join. That's great. Thanks so much. Hi. So welcome everyone. Um This is the second of our revision sessions and it's going to be covering psychosis and schizophrenia. So just a quick run through because we've got a lot to cover. So I want to be fairly speedy as much as I can. So just um, saying hi, welcoming everyone. Um, and then we'll cover the definition sort of the um, etiology subtypes of schizophrenia. And then we'll move on to the bulky stuff, which is the clinical features, investigations, differentials and diagnosis. And then finally the main thing which is the management and then we'll do a little bit of a summary and then if we have time at the end, we'll also do some MC Qs in the Polls. Um So keep an eye out for those at the end. Um Just to apologize, I have a bit of a cold. So I'm sorry if my voice is really croaky, but I hope um this is still really useful for you guys and um if you have any questions, just pop them in the chat and I will try and get to them as soon as possible. Um As I said, we've got a lot to cover. So I'm trying to be as quick as possible. Um But still cover everything. So yeah, you just let me know if there's anything um more that you want to understand. Great. So um starting off as just the definition because that's if you're new to this, if you've only just started your learning, it can be a bit confusing as to what is psychosis versus what is schizophrenia. So, psychosis refers to experiences where someone loses touch with reality and that is quite broad. So it can cover hallucinations which are perceptions without an external stimulus. It can cover delusions which are false, fixed beliefs and that are held despite rational arguments. And then it can also have involve a sort of formal thought disorder. And that can what we mean by that is sort of illogical, muddled thinking, that doesn't really make sense to anyone. Whereas schizophrenia is a type of psychotic illness and, but the psychosis is often a symptom of an underlying mental health condition. So, psychosis just think of it as a symptom. The same way we think of like dementia is not, it's not an actual presentation itself is a symptom of Alzheimer's same with schizophrenia and psychosis. So, psychosis is just a symptom. Schizophrenia is the illness and the reason we say that is because psychosis can exist with other illnesses such as severe depression or bipolar disorder, People can have psychosis with those. Um And it's just worth remembering that as well because rates of schizophrenia are much lower than the rates of psychosis which are a bit higher. So it's about 1% for schizophrenia and about 3% for actual psychosis. Um So thinking about schizophrenia's definition, it's pretty much defined into three main categories which is positive or psychotic symptoms. And we'll go into those later. But those can include hallucinations, paranoia, sort of distorted perceptions. Whereas then there's also the negative of symptoms, which is like trouble speaking, sort of very difficulty communicating emotions or having emotions, um not having any pleasure in things. And then we have a final thing of sort of disorganized symptoms and that can be the sort of thought disorder. But um kind of disorder thinking trouble with thinking logically weird behavior, sometimes odd movements. Um And it's just worth remembering. I put little stars for extra kind of high yield to the stuff where it's like stigma is a really big deal with psychosis and schizophrenia. So you remember that when you're speaking to patients and not to be afraid or come into it with, um, you know, preconceived notions of what it is, it can vary for different people. And the main thing I would say for most people is it's often they're more likely to experience harm than committed. So, moving on, we've got the etiology and pathophysiology of schizophrenia. So it's really good to cover the etiology because these are basically the risk factors and those are the ones you can get tested on. So, just worth remembering. So we've got genetics and it's worth noting that that's a big influence. So twin studies and adoption studies show that the lifetime risk increases tenfold if you have a first degree relative. So that's a huge increase. And if both parents of someone have schizophrenia and you're like, you have a 40 fold increase of developing schizophrenia. So it's a big, it's a big jump. Um Then obstetric complications sometimes happens. So you can have prenatal malnutrition, viral infections, sort of stress. Um like hypoxia and fetal growth restriction is another one that's a classic and then childhood adversity we call them like um aces, I haven't put that in there, but that can be a thing as well. And then urbanity and social disadvantage and people from lower socioeconomic backgrounds are more likely to develop schizophrenia as well as people who live in urban environments are pretty much twice as likely as to develop it as in rural environments and then migration and ethnicity. The 1st and 2nd generation migrants have on average, a three fold increase in risk compared to indigenous populations. And also Black Caribbean and Black African individuals have just higher rates and we're not quite sure why. And it's worth remembering that there could be some kind of underlying racism there as well and then substance use disorders. Um This is very significant for cannabis. Um So there's a dose dependent relationship with cannabis and schizophrenia and the worst is a particularly potent form of cannabis called skunk. And that's really triggering. And it has been linked a lot in South London towards accounting for about a third of the rates of schizophrenia there. Then moving on, you might be asked questions about the pathophysiology. I don't think these will come up as much to be honest in your MCQ. So I wouldn't worry too much, but you might be learning about them. So it's worth knowing. There are basically two theories. One is the neurodevelopmental theory, which is the idea that people with brain developmental issues, larger ventricles, things like that, or hypoxic brain injury are more likely to develop it. So potentially there is a link there. And the second one may that this is the most common theory, although it's, you know, my theories, it's been highly debated, but that's the dopamine theory and that's the idea that excessive dopamine and overactivity could be linked to the positive symptoms of schizophrenia. Whilst a lack of dopamine in other areas could cause some negative symptoms in schizophrenia. So that's why you sometimes see schizophrenic um behaviors in people with Parkinson's because they lack a lot of dopamine. So there's some things there. So there are lots of different subtypes of schizophrenia and um I've just covered six here and it's worth going into them a bit more detail than I can give you in this short amount of time. Um because it's quite a common question. I had that in my fourth year exams and it's really worth remembering them. The main one, the most common one is paranoid schizophrenia and that's with paranoid delusions and hallucinations, but you can have hebephrenic, which I know isn't on there. But um that's in the picture, at least. Um that's basically normally happens in adolescents and young adults and it's sort of more negative symptoms and the outlook is often quite bad and you have simple schizophrenia where it's just um similar to hebephrenic. Um and it's just the negative symptoms. Um But unlike um hebephrenic, they've never had any positive symptoms and never any hallucinations. And then catatonic is the one that's quite stereotypical in like TV, portrayals of schizophrenia where they have quite odd behaviors, they're very, either fixed in one position or they're quite chaotically moving all of a sudden. Um and they're very mute often. And then um there's also things like um residual schizophrenia, which is when the sort of negative symptoms are left over. Um and the positive symptoms have sort of burnt out and they no longer have them, but they did have them in the past. So, yeah, this is just a brief overview but definitely do um revise them more thoroughly and um they are quite a common question. So just a timeline of how people develop again, probably won't come up. But it's good to just think about it in this way, particularly in terms of arms as it's called, which was previously sorry for a little type. It means at risk mental state. And we used to use the term prodromal phase, but that's kind of lost come out of fashion because it sort of assumes that people will inevitably go on to develop schizophrenia if they have these symptoms. But that's not always true. Um Actually, about 20 30% of people who develop arms go on to develop psychosis and only half of those meet the criteria for schizophrenia. So sometimes people do get schizophrenic or psychotic like symptoms, but they don't necessarily go on to develop schizophrenia. And it just involves a kind of maybe very, very mild or brief period of the psychotic symptoms. And normally it's a change in function of the person. So they normally become quite distant isolating themselves in the room. And that can be a question and you can be asked whether that's actually a symptom of schizophrenia or just this um at risk mental state, then there's the acute phase, which is the most striking positive symptoms, the hallucinations delusions and then the chronic phase. And that's when you have more prevalence of the negative symptoms, which we'll go into later. But that's more sort of things like apathy, blunted affect. So they're, you know, facial expressions quite flat, anhedonia, which is a loss of pleasure and things in general that would bring you joy, social withdrawal, poverty of speech. And then hopefully at the end, we get recovery, um some people do remain with symptoms or in lifelong medication, but hopefully we get to a place where they're able to go about their normal lives and it's just worth going over in the corner there. Um Schneider's first rank symptoms, we don't typically use them as much, but they do sometimes come up in textbooks and things. So just worth going over them. So you're aware. Um and there is an OG guide on them as well. So then clinical features, this is the the big one we want to go over. Um because I've talked about a lot about them individually. So these are basically positive symptoms and negative symptoms and we normally split them into two. So I'll go over the negative symptoms first and, but remember that these normally come second to the positive symptoms, but it obviously depends on the type of schizophrenia, but they normally include a blunted affect, which as I mentioned, if you haven't done any psychiatry teaching it, don't worry, it basically affect is how our facial expressions are and normally we want them to match what we're saying. So if I'm talking about going on holiday, I might be smiling. But some people have a incongruous effect is what we call it. And it's when your facial expressions don't match what you're saying. So you could be smiling, but you're talking about genocide a bit to be very extreme about it. So in patients with schizophrenia, you're more likely to have a very blunted effect. So that means that there's just not much given away facially, it's very flat. Um There's very little facial expressions. Secondly, you're gonna have apathy and that's a lack of interest or effort in anything. Um You are just not that bothered by anything. You don't really have any keenness to be involved or not. It's a very much um the equivalent of, you know, when someone asks you what you want to eat and they say, I don't know, it's the equivalent of that. Um Then we have social isolation. This is a really telltale sign. You get that a lot in MCQ S of people suddenly withdrawing in their house bordering up doors, boarding up windows and no longer speaking to people including family members. So just watch out for that. That's a classic sign and positive speech. What we mean by that is just they don't really say much and conversation is very limited. Either one word answers nothing at all or, you know, normally in conversations, people encourage them to go further. You ask follow up questions. People don't, with schizophrenia don't do that. It's very sparse and minimal. And then finally, poor self care that just means often, you know, they're not washing, they're not even aware of that though. So, remember, there's a lack of insight so it's not a deliberate action here. Um It's just either I can't be bothered or there are more important things um or it's just not really noticed. So just remember those, often people forget about them with schizophrenia and just think about the hallucinations because those are the big signs, but often people can present with just the negative symptoms. So just remember those and particularly the social isolation. So moving on to the positive symptoms, um these are the stereotypical ones, but they also include a few others that you might not have known about or just forgotten. So good to reach out for revision. So the first one is obviously hallucinations and um as I said previously, it has quite a strict definition. So those are defined as perceptions without an external stimulus. So it's worth remembering that. Um and they can also include delusions as well, which we mentioned, which are um sort of these fixed false ideas and the whole point of them is that they are immovable to sort of rational arguments. So if you, you know, give them a reason why that's not the case. They won't, they'll ignore it and won't believe you. And you just have to remember with delusions that they have to be um out of context to what their cultural, social and economic or sort of religious background is because it's perfectly ok to believe that God is all around you if you are religious. So just bear that in mind, you sometimes have sort of tricky questions that will say that. And then a few other things that you might not have heard of, but thought echo insertion or withdrawal and broadcasting. These are all kind of come under sort of thought disorders. And that's when you either think that, you know, someone is inserting thoughts into your head or taking them out, um or other people can hear your thoughts. So that's broadcasting. And then thought echo is when you're thinking something and you can almost hear it. Someone saying it as if someone's almost narrating your thoughts. It's, you can imagine that really, really, really quite uncomfortable for that person to have that constantly going on. And then we mentioned a lack of insight that's classic and then passivity and somatic passivity. Those are the belief that a sort of a moment or an emotion or an impulse, something that you sort of do instinctively with your body or um your sort of, you know, emotional thinking is controlled by someone else it's quite hard to describe. But people can often say I felt sad but it wasn't me who was feeling that someone made me feel sad, but it came on to me, it's a bit of a weird one, but people will describe that to you. So next, let's move on to investigations. Um So these are just general investigations that you want to do, first of all, to rule out any organic causes because as we'll move on part of the diagnostic criteria is ruling out organic causes of schizophrenia. But you also just want to make sure that they're healthy in themselves. First, you know, often people with mental health problems, they have diagnostic overshadowing due to their illness and this is particularly true of schizophrenia. So worth doing a big sort of overview of their health as well. So, baseline blood is normal but we want to do particularly remember T FT S um can cause some symptoms like that as well as glucose because, you know, we want to check for diabetes, urine culture, a urinary tract infection can cause a delirium. This might seem obvious. But in someone who maybe is older, more frail, they could have developed a schizophrenic episode and they're not very good at distinguishing what's delirium and what's schizophrenia. It's worth remembering. And also people who are nonverbal or disabled in another way, you have to rule out these causes because they might not necessarily be able to tell you exactly what's going on. We also want to do a urine drug screen. Um, as I mentioned, you know, cannabis is a big one that can cause problems. Um but other things can be an issue like cocaine is another one HIV testing is a classic. Um It's just worth doing. Um And then same with syphilis because syphilis can cause in the sort of um tertiary syphilis can cause lots of psychotic symptoms. Um hallucinations, things like that. And then the serum lipids and baseline ECG is more useful for monitoring if you are going to prescribe antipsychotics, and we'll go over that a bit later in terms of management. But there's lots of things you want to monitor when you're giving someone antipsychotics because they are quite strong medications and can cause a lot of side effects. Um So I like to put in a baseline ECG is a good one to throw into a, for example, as well as serum lipids. And then finally, the only imaging you might want to do is a CT head if you think as an organic cause. And that's mostly not likely for anyone. But one of the cases I did have on placement was someone who had simultaneous um brain cancer like lymphoma in the brain. I think at the same time as having a schizophrenic episode. So it's, you know, these things can be, you know, contradictory or overlapping and it can be quite confusing. So it's really good to exclude that. Um if you do suspect there might be an issue there. So, differential diagnoses, these are really good to remember if you're doing an S or an ACC because people want to know that you are considering alternative things, even though it might seem really obvious that they've got schizophrenia, just throw them out there and just think, do a bit of research into them and why you would include or exclude them as a diagnosis. So the first one is an acute and transient psychotic disorder. And that's when psychotic symptoms appear suddenly and very briefly, they normally peak within two weeks, but then resolve within a month. That's quite common. Um I don't, I think I did put, I think I put down the one of the lists earlier but sorry if I didn't mention it fully, but that's a good one that can come up. So if it's quite short term, um that can be quite transient and then the schizoaffective disorder, a lot of people get confused as to what schizophrenia and what schizoaffective. Um it's quite a specific definition. So, schizoaffective disorder, it will have the same picture of schizophrenia. So the positive and negative symptoms, but it normally has a mood disorder developing simultaneously and it's the simultaneously bit that's really important. So, and because that helps you differentiate from when you have a mood disorder like bipolar that has psychotic features in that circumstance, the psychotic features normally come later after the initial mood disorder has developed with schizoaffective disorder, you have schizophrenic symptoms alongside the mood disorder and they occur at the same time. So just, yeah, that's the, that's the definition um delusional disorder. These are just the delusion parts of schizophrenia and they can last more than three months. They don't normally have mood disturbances, but they don't have the positive symptoms of schizophrenia like thought disorder, hallucinations and negative symptoms. And schizotypal disorder, um, is a bit of a weird one. It's a lot of people have, you know, odd views about whether it really exists, but it's a sort of enduring state where they're a bit, sort of odd. They behave quite with a lot of eccentricity. They can behave quite strangely, socially withdrawn, have quite odd ideas, but it's not enough to justify a schizophrenic like, um, da diagnosis and then just the other ones to throw in if you've got someone who's just given birth. Do you remember postpartum psychosis? Um, we did a talk last year which was really good about that. And that's, it's basically for a woman, your main risk, your highest chance of getting psychosis is postpartum. It's a huge risk. So, just worth remembering that. And then finally, personality disorders, I can't cover all of them. I'm afraid there was a lot and they've also recently changed the way that they're defined that people can have um, personality disorders with schizophrenic type symptoms in there, but it's normally milder and it's accompanied with personality disorder issues such as difficulty forming and maintaining close relationships, um not quite manipulative behavior, um, care seeking behavior, things like that. Um So those are just a list and it's worth doing your own revision to cover those, but they're good to mention in A and A CS. OK. So I mentioned earlier the diagnosis is made according to ICD 10 in this country, you also do see diagnoses made by the DSM criteria. Um If you are new to your learning, don't be freaked out by this. Basically, the ICD 10 is what like UK and Europe uses. And it's a worldwide classification of pretty much all diseases including mental health diseases. Whereas the DSM is more used in America and it's specifically just for mental illness, that's the main difference and they sometimes disagree slightly. It's the whole thing. But in this country, just remember ICU 10 and you've got two requirements. One is the fact that you have these first rank symptoms which we talked about and they must be present for at least one month. Just remember that and that can come up in questions and that covers what we talked about, which is the delusional perception of hallucinations and the passivity and then the delusions of thought interference. So the thought broadcasting, we discussed um the insertion withdrawal and then the auditory hallucinations as well. So, and the second part is that you have to exclude other causes. So as I mentioned, we have to exclude the fact that these lymphoma on the brain was not causing his symptoms and it was determined by the neurologist that it wasn't that it can be caused by other things like epilepsy, delirium dementia. Um you know, things like that. So just worth um making sure you've done all those tests as we discussed to rule those out. So moving on to management, I'm going quite quickly. So do put on the chart any questions that you have? Um I'm trying to race through it just so we have time to do some questions at the end as well. But yeah, if you have any questions or confusion, anything you want me to go over, just say. So, moving on to management, this is the main topic and um there's a lot to cover and a lot to think about. Um So I'm trying to frame it mostly to help you with your, if you're going on to psychiatry placement or if you need to revise for your exams and your sys um but it does slightly differ in real life as well, I'd say. So, um the main thing to remember, I think this is the page that's more important for your placement for your assessments like the A CCS. So just remember to mention you really need MDT support in schizophrenia. So this will normally involve a MDT team in the community or in acute CAD depending on where your patient is um it will involve psychiatrists, psychologists, mental health nurses. Um What else? Lots of people. Um I'm trying to think of all the various people that are involved. There's a huge team and they basically work altogether to figure out the best care. Obviously, the psychiatrist tends to be the one overseeing all of this and in charge of general management. Um So in this case, it's normally split into three MDT teams. So the first one is the early intervention team and this is where normally people were referred, if they have a first episode of psychosis, and they're really good and it's really good to mention it in an ac to say if this is their first episode, get them to the early intervention team because they can have a really good positive impact on their prognosis and development and community mental health team. Those are the ones that day to day. So if you had a diagnosis, but maybe you're managed now or you've been released from inpatient care and you'll returned to the community and they manage you ongoing to support your care whilst you're trying to go back into your life. And then finally, the crisis resolution team, you'll hear a lot of people talk about we need to get them into crisis or you should go to crisis. And these are teams that are located across the country and they tend to be people who are suffering from an acute psychotic episode and more broadly, any other acute crisis of mental health. So if they're suddenly suicidal, um or having a manic episode, they can go to a crisis team, but they're useful for those acute moments of psychosis. So then we can also think about admission to acute care. That can be the case in some cases. Obviously, it's always tried to be avoided as much as possible because it's quite a serious thing. And also beds are really limited. I mean, that's the main limitation. Um but they may require it if they are, have they lacked complete insight or they have a severe subtype subtype of schizophrenia like the catatonia. Um a lot of the times though it is voluntary and people can go there just because they need, they know they need that help, but they don't quite know how, what you know, how to get better, obviously. Um but if they are detained under the Mental Health Act, you've got to think about sort of long term provision, how that's going to work. And um it's worth going over the Mental Health Act or the various subsections because those do come up a lot in MCQ S. And finally, you just want to think about a risk assessment and people always forget about it and um it should be part of your mental state exam or M se we talked about that in our last revision session. So if you want to go over that and how to do a really good risk assessment. It's worth reviewing that it's on meal, it's free. So just have a look. Um I do say so myself, I think it is quite good. So um risk assessment just covers risk to self risk to others and risk from others. And as I mentioned at the beginning, in terms of stigma, you have got to remember that people with schizophrenia, I think are 10 times more likely to suffer from other people than to be a risk to others. So do remember that they are incredibly vulnerable because they have no insight and don't know what's really going on in the world. They have, they are completely disjointed from reality. So that makes you incredibly vulnerable as a person. And so do bear that in mind, particularly things like neglect. That's often a reason for impatient admission just because they are not coping at home. You know, they have, they are not able to wash themselves properly, eat a lot of people lose a lot of weight. So that's another reason for inpatient admission. So next we move on to antipsychotics and um this is the broad stay of questions. So it's really worth knowing these well, key points. I obviously, I can't cover everything but the key points are that oral atypical antipsychotics are first line. And that can be a bit confusing because you'd be like, why wouldn't you use the typical ones and what we mean by typical versus atypical is the typical ones were developed first and they are the original, original antipsychotics back from the, I think they were developed in the 19 fifties. Whereas atypical are the more slightly newer ones who that hopefully have less side effects. Although it can be a bit, um, they still have side effects but they're a bit better. Um, so also remember that everyone should have, um, CBT that has shown to have some effects and that you have to be very highly monitoring of the cardiovascular risk factors and modifying that and changing people's medication as a consequence because that comes up a lot. And particularly when you're counseling someone in sy about starting antipsychotics, you need to talk to them about that. So in terms of typical antipsychotics and these include the um sort of generalized dopamine receptor blockers and they like things like Erol chlor, I can never say that. Um and then the sort of depo injections of those and they have the worst side effect profile and they cause things called extra chraidi side effects and also the hyperprolactinemia. So the extra chlamydial side effects will go into this and a bit more. But they are things like parkinsonism and akathisia, dystonia, dyskinesia. Um and those are really severe, but they also cause hyperprolactinemia, which is when you have too much prolactin and a typical patient will come to you and they'll be like I'm suffering from CTOR. So, um so discharge from the nipples in men or in women as well. Um But particularly for having sexual dysfunction problems, that's another one as well. Um, osteoporosis as well is an issue and then they have metabolic side effects. So typically people will put on a lot of weight and that can be really severe and debilitating for them. So do think about that and counsel them strongly on that and about having a good healthy diet and doing lots of exercise, but it increases the risk of type two diabetes and hyperlipidemia. So obviously, you're more likely to have MS strokes, things like that. Um You also have anticholinergic side effects which aren't mentioned there. But um things like tachycardia, dry mouth and constipation. So think about if a patient is on antipsychotic medication, they can come to you. I saw a question that they had sigmoid ULV and that was because they were chronically constipated. Um So, you know, these things all do tie into physical health a lot and then the atypical antipsychotics, they're a bit more selective and how they block the dopamine receptors. As you see there, they block specific ones and therefore they are slightly better and then a bit less side effects. Um So these are things like OLANZapine, risperiDONE, cloZAPine, QUEtiapine and um they're just like less likely to cause the extra peridial side effects and the hyperprolactinemia, but they still have a lot of the metabolic side effects like the weight gain and the um hyperlipidemia. So just worth remembering that. Um and it's also worth noting I should have put this in the little star, but ARIPiprazole is um probably the best one in terms of side effects. So if you have a patient that comes to you and says they're experiencing these side effects, even on the atypicals, you typically would switch them, typically would switch them to um ARIPiprazole because it's a partial dopamine agonist. So it's less likely to cause the extra chlamydial side effects than the others. Meanwhile, cloZAPine also worth noting is used when both typical and atypical antipsychotics are no longer effective and we sort of reserve it. It's, I'd like to think of it as the equivalent of like a broad spectrum antibiotic. It's reserved for the worst cases. Um But it's, it's really much more tricky to give because you have to do a lot of maintenance for routine monitoring for agranulocytosis, which can be really life threatening. So, yeah, that's an overview there. And then if you go into side effects, talk to me a little bit about this, but the extra chlamydial side effects, um these include the parkinsonism, which we talked about. So if you've learned about that yet, it will be the sort of shuffling gait, the um you know, cogwheel rigidity, although actually they tend to have lead pipe rigidity on antipsychotics. But anyway, um these sort of tremors, things like that and then they get dystonia, which is when you have really severe muscle contraction, they go into sort of spasm, it's very uncomfortable for them. So, do, um, make sure that you change their medication. If they're suffering from that, it's not nice and it's very unpleasant when I've spoken to patients. Um, but that can be managed with procyclidine, um, if needed. So, Akathisia is this restlessness and I don't mean like they are bouncing their leg. They can be, but it's this internalized restlessness. They'll describe it to you as a, a need to move and a complete lack of Peacefulness inside the body. And then finally, the tardive dyskinesia, which is these sort of weird movements that they can get, which are completely involuntary and a lot of the times you'll see them like people chewing movements that can happen. Um So yeah, just think about always think about E PSE S as we call them. Then secondly, in elderly patients, it's worth remembering about the increased risk of stroke and venous embolism. I think this is a very small thing. I just put it in there because it's in nice. And I think it's more about actual patient care rather than would come up in AM CQ. But the other side effects would definitely come up in an M CQ. So do think about them. So the antimuscarinic ones, the constipation that I spoke about, the weight gain really big is really important. The prolactinemia. So the galactia or sexual dysfunction is another one that can come up impaired glucose tolerance. So they're more likely to stay at type two diabetes. Um, and then there's a few other ones I didn't mention before, which are worth thinking about, which is neuroleptic malignant syndrome. So, worth doing your own revision on this. Like, it's quite a big topic to cover, but that's when, um, they become, basically, they get, they have too much, um, antipsychotics almost. It's like an overdose but not quite in that, but it's not voluntary. They don't actually take too much, but the body becomes oversaturated and it typically presents with this pyrexia, which can be quite confusing because you think it's an infection if you have a question on it. Um So just make sure you read that medical history and if a um antipsychotic is on it, you want to rule this out as a differential because it can be really fatal. So worth thinking about. Um So think about um the reduced seizure threshold as well and then finally, prolong QT interval. That can be a good M CQ question. They might be like which of these drugs is most likely to prolong your QT how paradol mostly comes up. So moving on monitoring is therefore really important. Um We've got a lot of these drugs have really serious side effects and so there's a lot of monitoring that needs to be done and this could have come up in lots of different ways. I've seen it come up in MCQ S, but it could also come up in an A, as I said, if you're counseling a patient starting on an antipsychotic, you need to inform them of how often these have to be done. And um worth thinking about more broadly how that's quite a big challenge to do because you are dealing with people who are, who are anti, who are psychotic and therefore um quite apathetic to the healthcare lack, you know, necessary insight sometimes to remember to do these things. So it's about having that MDT approach, which is why they have these MDT S, you know, liaising with the GP and they'll often have their own mental health nurse assigned to them to check in on them to make sure they have all these tests done. So it's just bringing in that sort of multidisciplinary approach into your thinking. But yes, so just remember, you need the full blood count, use these LFTs and that needs to be done at the start and then annually and then obviously, the cloZAPine that we mentioned earlier, it can cause an agranulocytosis. So we need to really monitor that FBC initiate it becomes weekly. And then if it stabilizes you increase that, um how often you monitor bit by bit. Um But it's one of the things that sometimes you can, they could be absolutely stable and then have a checkup every three months or something. And then they will suddenly go into agranulocytosis and you have to start again doing it weekly. So it's, it's a challenging drug to give and monitor. Um Can we mention the liquids and the weight because of the metabolic um disorders that the um antipsychotics can cause? And then the same with the fasting blood glucose and the prolactin, um, make sure they don't become diabetic or have a prolactinemia, um BP, they can, can cause changes to your BP. It's just worth monitoring more. In fact, because of the metabolic side of things to make sure they're not going into hypercholesterolemia um or anything like that, it, it just increases the cardiovascular risk. So we just want to monitor the BP as well. An ECG I mentioned right at the beginning, just want to do that to check. There's not any weird disorders like or Parkinson white. So therefore, a drug that would increase their QT into four would not be great. And then as we said, obviously, do the cardiovascular risk assessment. So to go over, we've got prognosis and sort of some finish things up. And so it's worth thinking about long term, as we mentioned, it would be great if you know, people were recovered from this. But the um you know, and a lot of people do, but a lot of people are left on lifelong antipsychotics to um maintain their health and mental health. But just thinking about the likely options or prognosis of suicide. So suicide is 5%. Um So it's, it's small but it's not, it's not nothing, obviously, things like depression are higher. Um, but cardiovascular disease is one of the main killers. And actually, it's really worth thinking about if, even if you, as your GP, you've got a patient, they're much more likely to die young as a consequence of the cardiovascular disease than they are from the suicide or from the schizophrenia. Um, cancer is another one I saw obviously with the gentleman I saw in the, when I was on liaison psychiatry, for example, and that always stuck with me because his um it was quite tricky because his cancer kind of overshadowed his diagnosis and vice versa. And there's a lot of diagnostic shadowing and delayed diagnosis. So that will affect the M and mortality. And then remember about substance abuse, I think sometimes we have a bit of a conservative idea about substance abuse in um general medicine in psychiatry. You know, it's much more understood that most people with a mental health disorder will be using some, some kind of substance. And it's used quite understandably to as a sort of self coping mechanism. So try not to be too judgmental on it. You know, smoking is common. Cannabis is very common. Other drugs are common and asking to abruptly stop is a big ask. But it's important that you inform them about the risks of continuing to use it, especially things like cannabis if they have schizophrenia it's really bad for them to keep using it and you have to make sure they understand that. And if they can, you know, try something else, it would be much better. Um And then finally, just the social isolation, even when they recovered, there was a huge stigma attached, you know, people struggle to get jobs. Um you know, people often left on benefits and struggling to have good close relationships with people. So think about your patient holistically in terms of their sort of social side of things as well. And then just worth reiterating the factors associated with a poor prognosis is that can come up in MCQ S. So a strong family history, as I mentioned, genetics is one of pretty much the highest risk factor. So it also is a poor prognostic factor if it's a gradual onset, that has a very bad prognosis, low IQ. Um and then, yeah, a few others that are less important, but I'd say the strong family history, gradual onset and low IQ, the big prognostic factors for a poor prognosis. So just to summarize and then hopefully we'll have a bit of time for some questions. At the end, we covered talking about psychosis and schizophrenia and defining them. And schizophrenia specifically is a long term mental health problem that affects thinking, perception and affect, it affects about one in 100 people. So it's quite fairly common and it is associated with a lot of stigma even though it is not common. There are six main subtypes that we discussed a few others, but those are the main ones that come up in exams. So make sure you learn them and revise them. I don't think there's anything about that on passed, which is why I mentioned it because um you normally go by everything to learn about through passed. But they don't actually have these subtypes I think particularly listed. So worth looking into them yourself. Remember that symptoms can be divided into the positive and negative and don't forget about the negative symptoms. Most people do. So don't forget about them. You want to treat it with an MDT approach as well as um atypical antipsychotics which are first line and we went over the regular monitoring that is needed because of the strong extra pmid side effects, metabolic side effects. Um things like that. So at this point, we can go and ask for any questions and then we can do or we can move on and do some M CQ practice. But if you have any questions um type into the chat and um I'll hopefully try to answer I my, you know, obviously psychiatrist is my passion, but I'm not uh you know, for psychiatrist or anything, but I will try my best to answer any questions you have. Um I hope it was helpful and covered everything that you need. If there's anything else you want covered, um Please put it in the feedback as well. So normally if you want to get a certificate, so you've done this. Um You need to give us some feedback. It's really helpful. Anything I can prove on and other people doing future revision sessions can improve on. Yeah. Any questions please list if not, I will start with some poll which I've got ready so you can keep sending any questions you have. Um I'm gonna start with the first question. These are some Mc Qs from passed. I did not create them myself. Sorry, I do not have that time, but I hope that they are useful. Yeah, give them a go have a go at the pool. Got some responses coming in anymore. Don't worry, I feel wrong. So Carolina asked what if the patient refuses treatment. So that's what um the mental health factors for. Um at least in the UK. Um That's when it's used to forcibly detain someone in order to give them treatment. And um there's different acts under which you can do that. So you can give them sort of temporary 72 hour one. I have to revise it. I think that's section two and then section three is more long term. Um And you know that that will be done um normally more in an acute care, but it can be done in um hospital. I've seen that done if um they're sort of in liaison, um they can temporarily do that in hospital but yes, you will have to um give them treatment forcibly. Unfortunately, under the mental health Act, if that is deemed appropriate. And obviously, the Mental Health Act is its own topic in itself. But you have to have a psychiatrist, you have to have um, or two independent psychiatrists that are trained in performing a mental health Act assessment as well as someone called an who is a sort of social worker kind of thing. And they combine and they make the decision altogether to try and make it as fair as possible, but there's a lot of stigma attached to it. Um People, black people are much more likely to be detained under it. So they're currently reviewing it. There's a bit of a um quite a lot of um what's the right word um criticism attached to it quite rightly, quite rightly critic attention to the Mental Health Act. But yeah, ultimately, if patient refuses treatment and they have schizophrenia, they will probably most likely be detained under the mental health Act. So it looks like most people have responded. That's great. And the majority is correct. It would be uh ARIPiprazole. And that's because um it's the most tolerable side effect profiles we went as we talked about. Um So it's the, it's still an atypical but it's the most tolerable and it is um particularly good if you want to prevent um prolactinemia. So it's really good for that. Um So that's great. Thank you. Carolina. Glad that's helpful. Um, cool. Let's do this one. So I know they're a bit long but got to give you all the information. It sounds a bit more tricky. So I understand if you're struggling, we haven't really covered it. So I thought I'd throw it in there just because it's a good question. Any more answers. There we go. I think that's most people. Great. So, again, the majority is correct. But I know this is a bit of a tricky question. Um, so I thought I'd go through it. Um, the first answer to the, you mean the first poll or the, or Carolina's question about patient refusing treatment. The first poll, the first poll, the, um, with ARIPiprazole because it's the, got the best side effect profile and, and specifically good, um, for prolactinemia. So, if people are suffering from prolactinemia, you want to put them on ARIPiprazole because they're least likely to suffer it. No worries at all. So, this question about, um, her sister on risperiDONE and she's not basically been taking a medication. What do you do? So, it's a bit tricky because this is actually quite a common thing. So, the reason considering admission we wouldn't do because most people would think, well, why wouldn't you? Because that makes sense. But most people, a lot of people will not take their medications and if we all put them in inpatient care, it wouldn't be very good use of resources and it's not really necessary because actually they would be fine if they were taking their medication. Normally, inpatient admission is reserved for people who are quite complex and really struggling and need a lot of therapeutic input. In this case, we know the risperiDONE probably works because it says the symptoms were previously well controlled. She's just not taking it. So what we do for these people is we give them depo injections, which is something you'll see when, if you have had your psychiatry placement or if you're going to, you'll see, you can often shadow the mental health nurse when they go out into the community, give them and they're given subcu and they're basically just a long term release of the drug. Um Meaning that they don't have to take a day, remember daily tablet, but they still get their effective treatment. Um So it's really sort of the best approach um for non, for noncompliance and um you basically just have to retitrate them up to their previous dose. Um Similarly, CBT is a good answer. Everyone should have it. But in this case, we have been given the explanation that she was previously very well responsive to the risperiDONE. It's not that she's unresponsive to it. She's just not taking it. So in this case, the depo would be the best thing. Uh Great. We'll do, we can do a couple more and then I'll let you go because I know this is quite, you know, long and you've been with us for an hour. So thank you so much for sticking with it, but I hope this is helpful. Um Oh, it's very 5050. I'm glad you guys are struggling with this because I found this quite hard. Um And obviously we went over it with the sort of etiology slash risk factors. But I thought it was a good question to really consolidate that knowledge. So the answer is having a parent with schizophrenia. And this is because although they all are risks, as we discussed, having a parent with schizophrenia is the highest risk. So as I mentioned, I think the risk with a sibling having like a twin is um increased. Is it four fold? I think um yeah, no increase. So if you have a twin with schizophrenia, then there's a 10 fold increase or a first degree relative, but it's a 40 fold increase if both of your parents have schizophrenia. So genetics here is the biggest risk factor. And don't worry, I put long term cannabis use because as I mentioned, that is a big factor in people with it and particularly the really potent type called skunk, as I mentioned. So potentially it would be helpful if you knew what type of cannabis. Of course, if you were, if this was more real life based. But in the question, um cannabis use is a risk factor. But what we don't know is whether it's a direct link or whether it's more, it makes people previously already vulnerable because of genetic risks that it makes them therefore develop schizophrenia because they're already vulnerable and the cannabis just makes them a bit more vulnerable. That's what we don't know. So in a question like this, always think genetics as the biggest risk factor. Um I know it's tricky. So don't worry. But yeah, I hope that makes sense and we'll do uh one like final question, a bit of a I say slightly easier one, this one, hopefully, bye. Keep those responses coming in. And if not any other questions, you have just pop them in the chat as well. This is the last one, I promise. OK. So uh just by a small majority, the majority is right. So it's insomnia. And again, I know this is a bit tricky and I would, I think I found this one a bit tricky at first. Um because we sort of talked about like self neglect and not eating, but it doesn't mean they have a low appetite. The um the not eating is a consequence of the self neglect rather than an intrinsic rejection in appetite. And insomnia and sleep disturbances are one of the main symptoms of schizophrenia. And um although I know we didn't explicitly discuss it, that's why I thought I'd put it in a question. It will typically a MCQ or we discuss, you know, a patient who is not sleeping or having a very weird rhythm of sleep and the disturbance occurred in circadian rhythm is a big sort of alarm bell of schizophrenia. Low appetite is much more likely for mood disorders, particularly depression. And um that is one of the big signs of having a um sort of depressive episode. So I know it's a bit tricky but insomnia is the, is the main part of it. And then obviously the other ones, they're fairly easy. A family history of a psychiatric disorder would be more accurate. But Alzheimer's has no particular correlation. I hope that makes sense. Any questions put it in the chat. Finally, just a little bit of a plug. Um Obviously, I hope you guys are following us on Facebook and Instagram at so, but we just launched our new whatsapp group and in there we post, you know, all of the links to our events and also there's a separate group in there. If you have questions that you want to discuss about, you know, psychiatry placements or any psych questions, things like that you can post on there. So please scan the QR code join if you're obviously this is more for members of um the University of Southampton. Um But yeah, please join us and um yeah, do you um follow us on that? Otherwise, that's it. Um Thank you so much. I'm glad it was um helpful. And finally, the question was, do you need hypernatremia check after starting FLUoxetine? Um I think that you'd have to, um, double check that with, um, a senior psychiatrist. It's not a routine, um, check that you would do for FLUoxetine, um, FLUoxetine anyway, as a, um, antidepressant. Um, but yeah, I don't think it's necessarily needed but it might be if they are specifically hyponatremic anyway. And you're concerned. Um, but I think that would be, it would be good to have a discussion with the psychiatrist, you know, see a psychiatrist if that was a worry that you had. Um, I hope that helps. I'm glad you guys enjoyed it and thank you so much for getting involved with the polls. That's really nice. Um, and yeah, best of luck. Yeah. Thank you so much, everyone.