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Um Hello everyone. Um Thank you for coming to the Thursday to 15 or medic teaching session um on mental health or Psychiatry. My name is, has, I'm in F one in Stoke and I'll let Nandi introduce herself. Hi, I'm Nandini. I'm an fy one in Glasgow at Monklands Hospital. I think we're just going to wait for a few more minutes until most people are here and then start the session. And then of course, if any of the information is triggering for you too much, please feel free to leave the session at any point in time. You can always message us on social media and we can provide a link to the teaching session and slidess as well if you prefer to watch it in your own time because it's too close to home for you. Make it. I think we'll start at five past. Cool. Let me just see the slides work here. They do. Yes. OK. So it is. I pass. I think we've got a good number of people here. So just to explain the format, I'm sure we have people who have been to one of our lectures before, but we try to do it slightly differently where it's more question based rather than lecture. I was just telling you information. So we've got a list of questions and the first half or third of this session would actually just be going through the questions. So we'll have a timer, we'll give you about a minute to answer the questions and then we'll just click next. Um And I guess if you have a piece of paper, write down your answers. And then the second part would actually be us explaining the answers. So we'll go through the question, the answer, you know, brief clinical knowledge. And then from there maybe even going back to the question saying why it was this and maybe not this and stuff. So, uh if you are already, please do have your papers uh and a pen. Um Yeah, we've got um I think 17 questions again. Unfortunately, we can't cover every single topic, but here are some of the topics I would like to do. This is more again just testing your, you know, SBA or short answer question knowledge and that skill. Um Please do put questions in the group chat. If you have any, we'll try and answer them at the point. We want this to be as engaging as possible. Um If so, there isn't really much for us to say in the first half is just going through the questions. So, um hopefully you have your pens and papers ready. There's about, I think 17 questions but 17, I'm getting a nod. Um Cool. Ok, then, so we'll start a timer uh all the best question and then I would just click next basically. Ok, so here's your first question? Okie Dokey. Um Hopefully that wasn't too quick, but I think a minute is standard for answering your question. Um So hopefully you got your answers written down the plan now would be to go through each question. Um So Nandini did half. I did the other half and we'll go from there again. Any questions, please just put it into the group chat. Also, I'm going to put a feedback form while landing is talking. So please do fill it out. It helps us as well as medi teaching for building these sessions. Cool. I'll hand it over. Sorry, I don't think I can click through the pediatric mods. You put your mouse on it and move it and stuff. No, no. OK. Fair enough. I shall do the clicking for you. No worries. So question one, a 16 year old girl has presented with her mother to the GP. She has been refusing meals for the past few months and exercising excessively. She has a BMI of 17, which of the following may be found on her blood tests. The correct answer was two, which is a raised cortisol. And so just to work through some of the other options. So typically patients who have eating disorders and specifically anorexia, nervosa, which is what the stem is trying to get at um will have a low luteinizing hormone, um low estrogen as well as testosterone. And the way that I like to remember that is that oftentimes patients with severe anorexia um are amenorrheic. And so you can imagine if those hormones are low, you're just not going to have a period. Um You may think that a patient's cholesterol would be low if they aren't eating anything, but it does paradoxically become high. Um Patients often have hypokalemia and I try to remember that as they're not taking in any nutrients, so they're not gonna be taking in any potassium. Um And they also often have a raised growth hormone next slide. Please tell me once to click next slide and then I'll do that. Yeah. So the ICD 11 definition of anorexia is ABM I of less than 18.5. Um, a persistent pattern of behavior of restricted eating or behaviors aimed at losing weight and the fear of weight gain. Um Although I've heard just through my own clinical practice that psychiatrists are trying to move away from this definition of um having a specific BM I or a specific weight to diagnose anorexia. And it's more based on um patterns of behavior. So obviously, from your history taking, you'd probably be, be able to elicit at least from a collateral history, if not from the history from the patient themselves that they are maybe skipping meals. They sometimes patients don't want to eat around their family so they'll bring their meals up to their room because they don't want to be scrutinized for their patterns of eating. Patients often exercise excessively. They may take laxatives, which I think is typically seen, thought of as a symptom of bulimia, but it is also seen in anorexia. Um and they'll minimize their food intake on an examination. You may see lanugo hair, which is these thin, almost whitish hairs that cover the body. These develop in more severe anorexia to try and conserve heat because they've lost all their body fat. So, um, they're not going to be able to regulate their temperature in the same way. Patients may have a low BMI although be wary of patients who have a normal BMI and are still exhibiting these behaviors. Um, patients with severe anorexia may be bradycardic and hypotensive and you may also see that they have enlarged salivary glands. So it's worth seeing if they've got parotid omega. It may um put you in the right direction with regards to a diagnosis. Um, next slide, please. So as said before, when it comes to the investigations, it's really important that you do a full panel of blood tests because it tells you if people are having these kind of physical manifestations of their eating disorder. So low FSH, low LH, low estrogen and testosterone, which oftentimes leads to the amenorrhea, you have a raised cortisol and a raised growth hormone and you have an impaired glucose tolerance test with a low glucose. So, the way I remember that is, again, they're not taking in any nutrients, they're not gonna be taking in much glucose. Um, and your cortisol rises in er, the body's effort to try and keep the patient euglycemic. Um, patients will have a raised cholesterol and they'll also be often be hypokalemic um in terms of managing these patients, um CBT could be a really helpful approach as well as for younger patients, family therapy. So that involves mum, dad, whatever parental figures are there. Um and can be really beneficial because obviously, um parents are the ones who are seeing them, they need to be able to deal with these behaviors. And if there are any problems in the family unit, it can help to address them. Antidepressants can be very helpful in these patients. Um First line, I believe for anorexia is FLUoxetine, which is an SSRI in severe anorexia that may not be responding well with antidepressant treatment, um you can use antipsychotics and in patients who have um some of the physical manifestations of anorexia, nervosa, um they may need to be re fed through a nasogastric tube. This is something that you would do as an fy one, of course, this would be directed by psychiatrists, but it's always good to remember what guidelines are available to help. Um direct you as to whether this patient may need refeeding. And these are the me guidelines. So it's medical emergencies and eating disorders and they're really helpful and they're relatively new as well. These can be found readily online. Um Next slide, please. So for question two, you've got a 40 year old female patient that attends A&E with confusion and pyrexia. She's tachycardic and hypertensive on examination. She's found to have muscle rigidity and hyperreflexia. She takes sertraline and atorvastatin regularly and she's been recently started on a new medication by her GP which of the following medications may have caused her presentation. The correct answer is C which is sumatriptan and if you haven't guessed it, um, the patient has presented with Serotonin Syndrome. Um So out of the answers here, Sumatriptan is the only serotonergic medication. So that's in combination with her sertraline is what has led to her presentation next slide, please. So, Serotonin Syndrome is the name that's given to these group of symptoms that can occur with the use of serotonergic medications. So it's more likely to occur if a patient is on two or more serotonergic medications, but it may occur with just the use of one. It typically presents with autonomic dysfunction. So, tachycardia hypertension and hyperthermia. Um on a neurological examination, you may find muscle rigidity, they may be myoclonic and they may have hyperreflexia and they may also be quite confused. And I think what helps to differentiate um Serotonin syndrome from an infection, sepsis or sepsis of unknown origin is that hypertension, which you wouldn't often see in, um, patients who are septic, especially if it's a new hypertension. So, um, it's important to remember and just have in the back of your mind which medications are serotonergic. So, um, obviously, we always think of our SSRI S and our antidepressants. You may also have patients who are on pain medications like amitriptyline. Um, they may be on the monoamine oxidase inhibitors which are less frequently used for um depression. But for example, the SID is on there. That's something that's used um for the management of um infections. So, Gin is sometimes used in Parkinson's, I believe. Um and sumatriptan is one that is commonly prescribed for migraines. And so you want to just check that that's not interacting with a patient's regular medication. Um And so it's always helpful to just maybe go through the BNF if you do have in the back of your mind, that Serotonin syndrome may be um potential differential diagnosis. And that's why taking a good drug history from these patients or a good collateral drug history is really important. These patients are typically managed supportively. So give them IV fluids. They may be given benzodiazepines if they're particularly agitated and in really severe cases, they may be given chlorproMAZINE and Cipro heptadine. Um because these act um as like serotonin antagonists and next slide, please. So question three, a 34 year old woman presents to A&E after an intentional overdose. She has been experiencing low mood for the past three months since the breakdown of her relationship, which of the following is not a risk factor for the completion of suicide. So, uh answer two previous suicide attempts isn't a risk factor for completion of suicide. Um and will go through some of the risk factors both for attempting and completing suicide in the next slide. Thanks. So firstly, just to go through the presentation of depression, it presents with low mood as I'm sure you're all aware and hid Donia, which is kind of loss of interest in any activities or hobbies. Patients may often experience feelings of guilt as well. Um Maybe guilt over past actions, maybe guilt for the way that they're feeling. The fact that they do have low mood. Some of the somatic symptoms of depression are poor sleep. Patients typically have early morning waking, um which can help to differentiate it from anxiety which typically presents with um difficulty falling asleep. They may have poor appetite, a loss of libido as well as poor concentration. Um And of course, your severity scoring depends on firstly, how many symptoms are present um and duration. So some of the risk factors for attempting suicide are if your patient is male, if they have a history of self harm, history of drug or alcohol use, if they have any chronic diseases, if they're older, if they're unmarried, divorced or widowed, and if they're unemployed and then separate from that, you have your risk factors for completing suicide. And I think it's quite important to separate them out because you, especially as you go up in your training, you're going to need to assess, especially if you're going into psychiatry. Who are you most worried about sending home if they've had a suicide attempt? So it's always nice to have this in the back of your mind. So some of the risk factors for completing suicide are efforts to avoid discovery. So this could be that the patient has waited for everybody or family members to leave the home. Um Maybe they'll be going away for a weekend or if the patient has gone elsewhere, outside of the family home somewhere that they don't think they'll be found to attempt suicide if this is a planned suicide attempt, as opposed to something that's spontaneous that they've brought up just in the moment. If they've gone through the process of making final acts, for example, making a will or like the example, um in the question was arranging for pets to stay with family members. Um That's perhaps not something that you may think of as a final act, but it's something that may be really relevant in actual clinical practice. Leaving a note, I suppose that does come under final acts, but it shows that there's a lot of forethought there when it comes to the suicide attempt as well as if the patient's used a violent method to attempt suicide. So I suppose your main investigation is going to be doing a really thorough history from the patient. But you can use um some symptom scales to try and help um diagnose as well as determine severity of a patient's depression. You can use the PHQ nine scoring method as well as the beck depression inventory. Um But I think the PHQ nine is free and I think the beck depression inventory is something you have to pay for. Um in terms of managing depression, um patients can be managed with CBT, whether this is one on one with a counselor or a therapist or group CBT, if that doesn't work, um medications can be used. Um First line is always SSRI S and typically sertraline is the first one that's prescribed and then you can always escalate from there. You can do an SSRI and an SNRI. You can try a tricyclic antidepressant and for treatment resistant depression patients are often put on lithium question four, an 80 year old man attends the GP practice accompanied by his daughter. She is concerned that he may have dementia as he has forgotten her name several times as well as details about his childhood. On further questioning, he tells you he has lost his appetite and has been suffering from poor sleep. His ATS is eight out of 10, which medication is most appropriate to start for this patient. So the answer is C which is sertraline. So, if we go through the medications that are listed as options, you've got Donepezil, which is an Alzheimer's medication. You've got amitriptyline, which is a tricyclic antidepressant, um, can be used for depression, also used for nerve pain sertraline, which is an SSRI and first line for depression memantine, which is another Alzheimer's medication. And then Levodopa, which is used for Parkinson's and reading the stem. I think the differentials that would come to my mind are, does this patient have dementia? Cos there's uh the daughter is expressing that she's concerned that that may be the case as well as the fact he's had memory loss or does this patient have depression because he is expressing some of the somatic symptoms? And um as we'll get on to in the next slide, we'll just discuss some of the key differences. So, um I don't know if you can read the chart there. It may be more helpful if you'd like to take a picture, but some of the differences between dementia delirium is there as well and depression. So in dementia, often times, especially early onset dementia, you'll have short term memory loss. Whereas in depression, you get global memory loss. So if you go back to the stem, then you can see that the patient has um he's forgetting childhood events as well as the daughter's name. And so that's not really short term memory. So it doesn't fit with a typical picture of dementia. Um delirium, patients may also be confused, they may forget things as well. But the way that you differentiate it from dementia is that delirium may have a much shorter course, although delirium can last for months, but it's fluctuating. Um so, whereas dementia doesn't fluctuate typically, um and patients with delirium will often um be hyperactive or hypoactive. So they'll either be really sedentary sleeping all the time or very agitated. Whereas with dementia, you don't see this kind of acute fluctuating course, patients can obviously become agitated with dementia, but it does present over a longer period of time. Um in terms of dementia versus depression in the earlier stages, patients with dementia may not be presenting with kind of the poor sleep and the loss of appetite. Um whereas these are typical somatic features of depression and especially in the elderly, they tend to present more with these somatic features as opposed to coming out and saying I feel low. I don't have interest in my hobbies anymore. Um And so I think those are some of the key differentiating factors at least for me. Um Next slide, please. Thank you. So for question five, a 27 year old man presents to A&E after taking a paracetamol overdose with suicidal intent, he ingested 40 paracetamol tablets over a period of two hours before calling an ambulance to take him to hospital. So I think I've forgotten to put the answer in bold here, but the correct answer is B which is start him on acetylcysteine immediately. Um Next slide please. So when it comes to a paracetamol overdose, typically, for most patients, you want to wait for a full hour paracetamol level, you want to see where that falls on this graph. If it's above the treatment line, then you would start treatment with NAC or acetylcysteine. If it's below, then it's not needed. However, there some exceptions. So if the patients had a staggered overdose, which counts as taking the pills over more than an hour, then you need to start treatment immediately. If the overdose was 8 to 36 hours ago, start it immediately, you don't need to wait for a level or if the timing of the overdose isn't known. Um And the criteria for a liver transplant, which is something you'd think about later on down the line. If the patient's bloods aren't improving, are you have got a ph of less than 7.3 more than 24 hours after an overdose or all of the following prothrombin of more than 100 seconds, creatinine of over 300 grade three or four encephalopathy. And for these patients, you want to be discussing them with the National Poisons Information helpline as well as whatever your local liver unit is for me. Cos I live in Glasgow, it would probably be the Edinburgh Liver unit or the Glasgow live unit. Uh Next slide, please. So for question six A 19 year old man presents with auditory hallucinations have been present for the last month. He hears one voice that talks directly to him commenting on his appearance and actions in a derogatory manner. He has no family history of mental illness, which of the following is a first frank symptom of schizophrenia. So again, I think I may have gotten to put the correct answer involved, but the correct answer is three which is passivity phenomena. Although all of them may be seen in schizophrenia. Next slide, please. So just talking about schizophrenia, generally, some of the risk factors for developing schizophrenia are if the patient has a family history, if they are black or Afro Caribbean ethnicity, if they use cannabis. Um I think specifically cannabis as opposed to all drugs have been, has been related to the onset of schizophrenia. And if they live in an urban environment, some of the poor prognostic factors are if they have a strong family history or genetic predisposition, if they've got a low IQ, if it's come on gradually and they've had a prodromal phase of social withdrawal and if there's a lack of an obvious precipitant next slide, please. So some of the first frank symptoms of schizophrenia, which are typically how you diagnose schizophrenia. Although I do think this has been taken out of the latest edition of the DSM, it's still quite prevalent in MC Qs. So there's thought disorder, this can include thought echo. So they feel like everybody is hearing their thoughts broad broadcasting as well as thought insertion, which is the idea that somebody or some force is putting thoughts into the patient's head that aren't their own. That's number one, there's passivity phenomena which is actions, impulses or feelings, which are being imposed on the individual. Um So maybe the individual feels like they're being told to hurt somebody else and they feel that this isn't them, that's thinking that they feel like there's some other sort of force making them feel this way, auditory hallucinations. So typically 12 or three voices talking directly to the person, um or and commenting on the person, um and delusional perception. So, um believing phenomena that isn't there. Um Some of the other symptoms of schizophrenia are lack of insight. Patients can be really agitated, they can also become catatonic. Um They often have disorganized speech and they may have neologisms which are these kind of new made up words that are already known to them and they may have a really flat affect as well. Um Next side, please. So some of the investigations that you do again, really thorough history, it's always key in psychiatry, but you want to do routine bloods because you want to rule out any sort of organic cause. Um You may also want to take some serum lipids because these can become quite important when it comes to initiating treatment. You want to do a urine drug screen because um there are different recreational drugs um as well as alcohol that can induce psychosis and that's a potentially reversible cause. And you also want to do a CT head on these patients. If you do suspect that there may be an organic cause in terms of management, patients are often started on antipsychotics. CBT can be really helpful for these patients as well and for patients that um have severe schizophrenia when it's indicated and often patients who are catatonic, they may undergo ECT which is electroconvulsive therapy. Question seven, a 23 year old male patient attends for a review of his treatment resistant schizophrenia. He has no other significant past medical history. His bloods show the following. So a hemoglobin of 100 and 30 a white cell count of 2.4 platelets of 276 0 neutrophils, lymphocytes of 1.7 which medication is most likely to have caused his blood results. Um The correct answer is D which is cloZAPine. Um And I think two key factors are obviously the deranged blood results and the fact he's completely neutropenic, he's got agranulocytosis, but also just in the sense stem, it says treatment resistant schizophrenia. So, cloZAPine isn't normally started until a patient's tried at least two other antipsychotics. Um So that could point you in the right direction. Next slide, please. So here's a chart with a list of some of the antipsychotics as well as some of the typical side effects and adverse effects that may occur as a result of them. So, in terms of typical um side effects from antipsychotics, they may develop extrapyramidal side effects, which includes parkinsonism akathisia, which is this restlessness, dystonia and dyskinesias. Um they and tardive dyskinesias are particularly like your lip smacking, et cetera. They may um develop hyperprolactinemia which can lead to sexual dysfunction, amenorrhea, galactaria, patients also may have metabolic side effects. So, weight gain um is typically seen in a lot of these patients and that can lead to the onset of type two diabetes. Um and patients may develop neurological side effects such as seizures. Um the first generation antipsychotics are generally worse for the development of these side effects. So these include haloperidol called promazine. Um Your atypical antipsychotics are a bit better in terms of their side effect profile, but they can still cause all of the above side effects. Um cloZAPine in particular is known for causing agranulocytosis. Um any of them can cause it but in terms of multiple choice questions or be cloZAPine, that's the correct answer. Next slide, please. So questioning I think is yours. Yes. Question eight, a 21 year old woman presents to the emergency department reporting suicidal thoughts following an argument with her boyfriend. Longstanding difficulties with relationships, frequent arguments with friends and family denies any paranoid thoughts or unusual beliefs. Sometimes hears her voice in her head describing negative thoughts during the consultation, multiple superficial scars on her forearms, you do not notice any unusual speech or evidence of delusions. So this one is borderline Personality disorder. The answer is a. So um let me give my explanation first and then I'll come back to it. So, I mean, this is an example of classical EU PD or borderline personality disorder, fluctuation of mood. Another important thing just to highlight is in personality disorder, the patient needs to display this behavior before they were 18 and then also continuing after 18. Um So because, you know, in the issue was persistent behavior, um then you can think about personality disorders. Um So yeah, borderline would be fluctuation of mood issues with self harm issues with forming relationships or wanting to be in relationships. They would say that in relationships, they can be somewhat fine, but then outside is where they get this fluctuation in their emotions. Um in terms of paranoid schizophrenia, they have difficulties in trusting people. Um, schizoid is when you have a cold personality um that you're actually non reactionary to different situations. Um Yes. So then when I go back to the answer for this, I've explained why it is borderline in terms of paranoid, it wouldn't be paranoid because she says she doesn't have any unusual thoughts or beliefs in terms of schizoid. She doesn't have this coldness in her character because she's displaying a fluctuation of her emotions. It wouldn't really fit that criteria. Schizophrenia wouldn't necessarily be that because we've not really explored or the patient hasn't said anything about psychotic type symptoms. Um So that's the reason why it is a, um, this one is mine as well. Yes, it is yours. And ok. Um, so question nine, a 47 year old man presents to his GP practice for a routine check up. He mentions in passing how he believes that the COVID-19 pandemic was fabricated by the government. His speech pattern is disorganized on questioning. He has no friends as he does not trust others easily. He tells you that he has been considered eccentric since he was young, which of the following diagnoses is most appropriate for this patient. So again, this is another personality disorder question. So um the correct answer is c which is schizotypal personality disorder. Um and just going through the latter two. So Autism Spectrum Disorder, I don't think this man is actually showing any symptoms of autism at all. But I think patients who are like this who may be considered somewhat eccentric um could potentially be misdiagnosed with something like autism. So it's really important to um be able to clearly differentiate these personality disorders um and be able to compare and contrast them to something like autism. Um in terms of avoidant personality disorder, these patients typically like avoid responsibility for things they hide behind any sort of authoritative or parental figures and he's not actually expressed any sort of behavior like that. Um And then in the next slide. Um we're gonna talk about the differences between um yeah, schizophrenia, schizotypal and schizoid and just to go back to autism, it um he's not actually expressed any kind of repetitive patterns of behavior or a need for a particular particularly structured environment. Um Although he did express that he has difficulty with socializing, but it comes from more of a place of paranoia, which I think is what can help differentiate Um this patient in terms of it's actually a personality disorder as far as opposed to something like autism. So something I always struggled with was differentiating these three different diagnoses. So for schizophrenia, a patient is experiencing hallucinations and delusions. And in schizotypal and schizoid, they are categorically not experiencing hallucinations or delusions. So the patient expressed that he thought the COVID-19 was fabricated by the government, which it's an odd thought. Absolutely. But first of all, this is a thought that is surprisingly shared by many people. It's not an isolated delusion like just for him. Um And on further questioning, he would have um you would have seen that he is kind of in touch with reality in a way that schizophrenic patients are not. Um all of these patients do have interpersonal difficulties in schizoid, they're completely indifferent to other people. Whereas in schizotypal and schizophrenia, they may want to connect with other people, but they don't know how and they may just feel more anxious about doing it as opposed to not caring completely. Um In schizophrenia, patients have completely disorganized, thought they'll use the neologisms which are made up words. Um They'll have really scattered patterns um of thinking. In schizotypal, they may have slightly disorganized speech but they, they don't have a thought disorder as such. Um And again, in schizoid personality disorder, they don't have a thought disorder. So I think just to summarize, I think schizoid cold, completely indifferent to social interaction. Schizotypal odd ideas, somewhat disorganized speech, but no actual delusions or hallucinations, schizophrenia, hallucinations, delusions, not in touch with reality. Uh Next slide, please. OK. Cool. This is mine. Long question, somewhat paraphrase it. Patient comes in a gp 30 year old woman diagnosed with generalized anxiety disorder already on sertraline. Today's come with worsening of her symptoms. So it does not feel sertraline is helping anxious all the time, frequent episodes of heart pounding, struggling with sleep. Uh You observe and she's distressed. So what would you do in this situation? And the answer is change the prescription to DULoxetine. So um let me just give some explanation about generalized anxiety disorder. So we're gonna go through a few anxiety disorders of my questions. Um Gad is excessive worry about a number of different events. So they, if it's one particular thing that makes them anxious, then you're thinking about a phobia or another anxiety disorder. But because it's a number of events or they're just generally anxious that will be defined as gad when a patient comes in, you need to rule out these differentials, um hyperthyroidism, cardiac disease. If they've got any arrhythmias or abnormal heart rhythms, medications can induce these and these are common ones that patients can have overuse of altol theophyllines, corticosteroids, antidepressants in the first few weeks, they can cause um you know, tachycardia or heart pounding or actually heightening of anxiety. And actually, that's something that you tell patients before you give them an antidepressant uh caffeine as well. Um So in terms of management for generalized anxiety disorder, first is just general education about it. From then you can go for low level CBT. So that will be group based. And then stage three, that is when you're thinking high level CBT. So that could be 1 to 1 focus and then you're considering drug treatments and then following there it is a specialist would deal with it. So actually G ad is normally treated by community based teams or I guess nonspecialist like GPS. So did I have a slide about medications? No, I didn't. OK. So, and in terms of if you go back to the question, normally you um start an SSRI, you go to the maximum dose of it and then from then you go to another um medication. So socially tends to be given. Um And then the second choice is actually to try another SSRI um or an SNRI and that's what DULoxetine actually fits in as an S sra meta is an SNRI um pregabalin can be used but that's like, you know, second or third line increasing dose. I think that's the maximum dose diazePAM that is more used at the height of anxiety that they take at the time. We're not at that level at this stage that's mostly used in hospital. So I don't if you have explained why the answer is a or number one? Ok. Er, question 1118 year old sprinter preparing for the national athletics meeting, asked to see the team doctor with you for unusual sensations in his leg describes a numb sensation below the knee, apparent sensory loss below the right knee and the non dermato distribution. The doctor suspects a non organic cause. This is an example of and the answer is conversion syndrome. Ok. So let me start explaining about the different medically unexplained symptoms. So a lot of these are actually diagnosed by exclusion. You're meant to look at organic causes and then from then you're looking at these, you know, uh psychiatry related diseases that could be causing these somatic symptoms, these physical symptoms. Ok. So I'll break it down for a few. Um somatic is a multiple of physical symptoms that you develop over two years. Also, this patient tends to not engage with wanting to diagnose their condition. So you need a long history of this and unrelated symptoms. Ok. Next one is hyper chondrosis or illness anxiety disorder. This is someone thinking they've got a very serious disease. Um when in fact, you know, nothing is really going on or they're hype or worried about certain things or let's say they've got abdominal pain. Therefore, they're thinking cancer. Now, obviously your job as a doctor is to rule out the cancer. But if they're still maybe even distrusting what you're saying or refusing to accept, then you're thinking about this. Ok. Um Next is Conversion disorder, which is in this case, which is, it tends to be patients who just describe loss of motor or sensory function. Um They're not feigning the symptoms, they're not faking it. So let's say our patient that we have is an athlete is probably very stressed about an event, you know, the national athletic tournament that he's going to and then he develops these symptoms, these abnormal symptoms, you could say there's loss of motor sensory function. So that's what we call conversion uh disorder, fictitious disorder. That is when someone is faking symptoms. Um So, um let's say in this case, he doesn't actually have sensory loss. Um but then says, I've got the sensory loss, so he's not faking it at the end of the day. Malingering also called Moon Chons Syndrome. That's when you're faking it for a calls. Um Commonly, it seemed like let's say A&E a patient may fake symptoms to want medications and they're doing that on a regular basis like, you know, wanting pain relief because they've got some sort of addictions or they're faking symptoms because they want to get out of something or some sort of financial game for, you know, insurance or something. And dissociative symptoms is uh the feeling of feeling very separate to your body. Ok. So hopefully I've explained why it is conversion syndrome because in our case, it is the loss of sensory function. Ok. And he's not faking it. Question 12, you're on a psychiatry liaison rotation. Uh You've been asked to talk to an admitted patient with known bipolar disorder upon taking a history, you struggle to follow the stream of consciousness as he keeps saying things like I went home to feed my cat so fat I am, I really need to lose weight. I hope the postman, he always speeds up in his red. Van Dan is my best friend at work. You, you suspect that his flight of ideas is linked by only rhyme or similar sounding words. This will be clang association. So let me go through some of these definitions that you need to know in psychiatry circumstantiality. That is when um you, you ask the question, you go off topic but uh you do eventually come back, you come back to answer the question or you come back to the topic. OK. Tangentiality is when you are asked a question and then you're just slowly getting further and further away from the topic. Each sentence may have an association but you at the end you're so far that the patient doesn't even probably remember what they were talking about and they probably can continue talking neologisms. That is when a patient is forming new words or combining words. Um It's hard to describe until you really see it at the end of the day. But um so they are somewhat making some sense, but they're creating these new words, Clang Association. That is in this case, this is where words actually start rhyming together or sounding very similar. Um I didn't actually put it here, but the thing that I get confused is clang association with Eco Loa, which is the repetition of certain words or the repetition of certain ideas. Um Think of it as echoes or the repetition of a noise. Yeah. Words solid is actually you're just saying words are very incoherent, maybe even they don't, they're not actual words and the senses have no structure at all. And then nights moving, that's a quite severe presentation. If someone has it, that's a loosening of association and illogical leaps from one idea to the next. And you get that in schizophrenia. OK. So, um this patient could have mania, but that's not quite the symptom a phase. Wouldn't be that eia again, we said that's the repetition of an idea and the patient is not making up new words. These are words that we know it's just that there's just no association and it's, you know, um similar sounding OK. Question 1325 year old man has a change in mental status of the last month. He stayed up for the nights writing four novels, not been eating and drinking. Um, refusing to engage, started gambling during the consultation, e distracted sentences that make sense, saying random words, no drug misuse. Er, he has a history of depression, um, and he feels people holding back from achieving fame. So the answer is bipolar type one. Ok. So let me explain about psychotic disorders. So, psychosis, the three defining features of it is hallucinations. It could be ay, it could be visual development of delusions. The psychosis is when you've got an impairment of understanding what is going on impairment to reality at the end of the day. So, hallucinations is what you're seeing or hearing things that may not be there, delusions, these are strong beliefs that the patient may have or thought disorganization. That's your alienation and all those sorts of things. Um all um problems in the thought disorder. So like as we talked about the words are and, and all that associative future would be aggressive, agitated behavior. Um again, it has to be persistent because if it's more acute, then you could be thinking delirium. Um but if it's been lasting for a longer period of time, then you, you are thinking about psychosis, um it can be associated with depression, you can have depression secondary to psychosis. In this case, it's a, we'll talk about it why uh the thoughts of self harm can also be associated with this. So, um with psychosis, uh you need to think about the other differentials. Um And let me try and talk about the defining factors between that. So, schizophrenia is the most common that can be associated with schizophrenia. But then as I had explained, you need the first rank symptoms. Um and then you look at the second rank symptoms and then if its like here, then it will be done. Uh bipolar disorder. In our case, this patient has no depression and then it in a manic state or it could be in a hypomanic state. So these patients mostly spend their time in depression and then develop many in a hypomania. Um, yeah, whereas menia you be in a manic state most of the time, the heightened anxiety and delusional thoughts and gambling behavior, it doesn't seem like it's persistent in our patients. It only seems short term and then what would end up happening is it will come back into depression, pupil psychosis. Uh, that's a very severe form that'll be in er, post pregnancy. Um, what else have we got here? Corticosteroids. It can be drug induced as well. Um And normally the peak episode is in younger patients between 15 and 30. So coming back to it, it's type one rather than type two because there is these obvious psychotic symptoms, holding back from achieving fame. Um, disengagements. Um, like you could say writing four novels could be hypomanic, but I would say holding back from the vein that's like delusional type thoughts. It's not man yet because a patient has a past medical history of depression. Um, and it's not schizophrenia or schizo type of personality disorder. This is not persistent behavior. Okey dokey question. 14, a 21 year old woman, er, complaining, er, has been experiencing persistent intrusive thoughts and repetitive behaviors. Specifically concerns about contamination and excessive hand washing, gradually increasing, increasing and having um a negative effect on the hands as a result. And further questioning, persistent thoughts about harming others avoiding sharp objects due to fear all of this caused her to miss work and avoid social situation, causing a significant negative impact on her daily functioning. What was the most appropriate course of action? The answer is d referring to secondary mental health team and starting treatment on SSRI S whilst you are waiting. So if you didn't know in this case, this is O CD. So let me try and explain what that is. So obsession is when you got an intrusive thought, intrusive meaning a a thought that keeps on coming in your head and is very bothering and is repetitive to the point that it becomes very distressing to the patients compulsions is repetitive behaviors. Um and the patient feels driven to actually having to do it. Um that could be excessive washing their hands or yeah, I mean that's a classic example or cleaning things at the end of the day. Um So you can have one or the other in OCD, but it has to be for a persistent period of time to have that diagnosis. And that's part of the anxiety umbrella. Ok. So in terms of treatment, my would be you can have CBD CBT or you can potentially start E RP but that is in moderate. Um You would think about using an SSR but you could hold it, then you've got moderate OCD, then you start an SSRI, then you look to do your E RP. Um And then in severe cases, it would be actually secondary care referral for that. It seems to be a lot of OCD patients when they do actually present eventually to their GP or um their GP or, you know, psychiatry that they're more moderate to severe. And that's why you end up starting to think about referring to secondary care services because this is considered like a very advanced disease. So like when I was answering this question for me, it was either C or D. Um but I think once you get into the stage, you get to E RP, that's when you need to get secondary care involvement. Um And then whilst you're waiting for it because it is an anxiety related disorder, you would still give an SSRI while you are waiting, most likely sertraline second line, you can give clomiPRAMINE. Um So, yeah, OK. Question. 1546 year old driver attends the GP three months after she was involved in a road traffic collision. You take a full history. The patient is unable to remember details of the events but getting into a car makes her anxious. She avoids driving. She's concerned she may lose income as a result. Um has recently been compulsively purchasing clothes and electronics online is also having to rely on sister for help for certain passengers, cooking and cleaning her house because Anne does not have the motivation for this house and informs you the number of occasions recently where she's been described as reckless by her sister when crossing a busy road near their house, which of these details would point towards a diagnosis of PTSD. The answer would be avoidance of driving. So we'll talk about the other symptoms as well and why that's actually occurring. So PTSD is when a patient develops of traumatic events, then they develop this heightened anxiety that if they were to be re exposed to that event. Yeah, they develop this anxiety. If it's within less than four weeks of the event, we call it acute stress reaction and then you don't really do anything that's the watchful waiting after four weeks. If it's still persistent, then you're thinking in PTSD, here are the three defining factors for PTSD re experiencing the event. So they can complain of flashbacks or nightmares, avoidance of behaviors or the situation. So let's say in this case, it would be the car, avoiding being in a car. But let's just say she didn't like the honking noise. So then she'll avoid being around horns like those horns that people press. Um Yeah, so you would avoid being around there because that would somewhat still remind you another one is like, you know, um let's say uh army soldiers and they come back from war and then certain smells would trigger them. So then they will avoid being around certain things or certain colors, for example, and then hyper arousal. So that's in that moment, let's say if you were in a car, of course, being in a car can be stressful because you know, the accidents can occur. Um, and you need to be aware. However, being that hypervigilance giving that over anxiety that would be considered abnormal, that's what hyper arousal is. Ok. So in terms of management, first four weeks, you don't do anything that's acute stress reaction. But then after four weeks, those that are military related, you can refer to army resources, trauma focused CBD can be offered and then also E MD or rapid eye movement desensitization therapy. Um You can give an SSRI but that's considered, er, it's not first line, I think from then you're probably referring to secondary services. So, avoidance of driving behavior that falls into one of the three, symptoms that we talked about, er, inability to remember the detail of the collision now it could be, is it actually an inability or they just avoiding thinking about it because even them talking about the car accident that can trigger their symptoms? Ok. Convulsive online shopping, it seems like this patient has developed secondary, you know, coping mechanisms and one is shopping, but that's not really PTSD related, increased reliance on family members. That could just be this patient called PTSD and then secondary depression and they're not able to look after themselves. That's why they're having reliance on other people as well as I think she was saying she was having financial problems and then reckless behavior again, that could just, it was reckless, actually went crossing the road again because of the heightened hyper arousal, maybe having that. But that's not classical or PTSD, that's more of a coping mechanism. Ok. So that's 50. Um I think this is the last one or is the second, is the last one? Ok. Um Question 1675 year old woman seen by GP with concerns of memory. Extremely worried. She cannot remember. Recent conversation. Husband confirms they have repetitive conversations. This has been going on for five weeks and started after the patient's sister before she passed away over some periods. She had low mood, low energy reduced appetite, poor sleep concerns as reluctant to go to memory clinic and take diagnostic tests for dementia, which of these factors would lean towards a diagnosis of depression. And the answer would be memory loss of recent events. Ok. Oh, diagnosis other than depression. So more towards dementia that be uh memory loss of recent events. Ok. So um I know Nan had covered it so I'm not going to go into too much detail, but here are just the things that would lean towards depression over dementia. So short term memory loss in dementia, it would be short term because what is they are able to remember long term things or their background or memories with their husband or wife or kids. But short term, they won't be able to formulate new memories. Whereas in depression, it would be more of a global amnesia. A global loss of memory. Um biological symptoms are more seen in depression. Um weight loss and sleep disturbance patient worried about poor memory in dementia. They probably don't have that cognitive ability to think about that. Whereas in depression, unless it's severe depression, um they are actually probably concerned about it as well or maybe have insight, reluctant to take tests disappointed with the results. I'm not saying in dementia you could be agitated and aggressive about that. But in depression, I think because you have that lack of affect and engagement, you wouldn't want to have tests done on you. Many mental say examination would be variable in depression can be variable in dementia, but it's more variable in depression because again, your mood can fluctuate and then a global memory loss, as I said was in dementia, it would be certain memories, it's more short term memories that can't formulate new memories. It's long term that they're able to retain. So in our patient, patient concern over memory loss that would lean more towards depression than dementia in dementia, you wouldn't really have insights, reluctance to engage in memory test. Um So let's say in dementia, you probably would be more on board with it short history that would lean towards depression rather than uh dementia and then sleep that lead towards depression rather than dementia. Ok? And then I think this is the last one, 80 year old man with his wife presents to the emergency department says he has been more forgetful over the past month, not being able to concentrate and continually leaving the fridge, open wife expressed concerns that he's been seeing monkeys standing behind him on multiple occasions. Past medication includes type two diabetes and hypertension over 15 years ago. Most likely diagnosis in this case will be Lewy body dementia. So let me talk about for dementia and I'll briefly talk about the others. Um I found this not more confusing, I guess in the dementias, especially in psychiatry. So what is Lewy body dementia that you get these Lewy plaques that form in your brain? It is classed as a dementia, you get progressive cognitive impairment. Whereas in vaso stepwise deterioration, parkinsonism is associated with lower body dementia. Um visual hallucinations is also part of it as well, which we've seen in our case, in terms of diagnosis, it's normally clinical, but there are some you can do a spect examination on these patients as well, which is using radio ISOS to actually identify where these Lewy body plaques are. In terms of management. It's actually very similar to other dementia conditions using uh Donepezil and memantine are those that can be used. So let's talk about our case. Um forgetful over the past few months. So that will rule out delirium. Um Then as you can see, leaving the fridge open, that just solidifies more so that this will be dementia because unable to manage themselves. Then it's the delusions at the end of the day. So this patient says he's been seeing monkeys on multiple occasions. That's why he's leaning towards lower body dementia. Now, obviously, I threw in the type two diabetes and the hypertension. But because of the pattern that is like a progressive cognitive impairment rather than um a stepwise deterioration or let's say a patient was like, I recently had a stroke and then developed these symptoms. That's why you're not really thinking about vascular dementia for this case. OK. Dokey. Um I think that's the end. So thank you for listening. Um If you're still with us, please do fill out the feedback form. It is in the group chat. This really helps me and, and, and our team a lot because we take this forward to improve our sessions. Um There you go. The feedback form is right there. Um Anything else you wanted to say Nandini? Um If you do have any questions, please feel free to. Oh, I see. One. Would you mind please quickly showing the answers to 12 and three? I step bug. I'm clicking as quick as possible. A few. So I'll go to one first and then I'll click forward. Ok, there you go. So number one was raise Cortisol. Uh question two was Sumatriptan and number three or previous suicide attempts. Did you need anything else Lauren or was that all for? All right. I think that's all fine. You guys up with any questions um After the session, uh please feel free to like message on social media on Instagram or Facebook, someone will get back to you. Um And if you fill out the feedback form, we will send you the slides. So that's a cheeky little incentive there. Um Thank you all so much for coming. Uh I hope you found it useful. Five M. See you later. I'm going to head off, man. I've got another meeting at half days. So, but thank you for doing this. I enjoy doing another question. So it, Serotonin syndrome are not neuroleptic malignant syndrome. I think neuroleptic malignant syndrome, I'm just actually bringing up my notes. So with that, I think it's typically caused by antipsychotics as opposed to your antidepressants and your serotonergic medications. That's the way that I remembered it in um uni and you get more hemodynamic instability whereas you typically see hypertension and serotonin syndrome. And so if you got hypotension, um and hyporeflexia in neuroleptic malignant syndrome, I believe. Ok. Does that make sense? So, antipsychotics are so, yeah. Um antipsychotics are the precipitant in neuroleptic malignant syndrome whereas it will be SSRI s or serotonergic medications and serotonin syndrome in neuroleptic malignant syndrome, you get hypotension and hyporeflexia. Whereas in serotonin syndrome, it's hyporeflexia and hypertension. Cool. Um Any other questions? I'm just gonna wait for one more minute because just in case someone is typing. Um, ok, I think we're done. Um, thank you for coming. Hope you have a nice evening. See you one. Bye.