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Hi. Can everyone hear me? Yeah, I can hear you. Ok, great. Um Let's just give it a few more minutes to let people join and then we can stop. Mhm. Ok. Um let's just start now and then people will join, join. Um So hi guys. Uh my name is Pavia. I'm one of the fifth years at Manchester. Um I'm just gonna be hosting the session today, so I will be just keeping an eye on the chat and things. Um and yeah, today's session is gonna be um the first hour of poetry teaching by then and then the second hour is gonna be os practice, which is really useful. So try and stay for that. Um But yes, without further ado I will hand over to you then. Ok, wonderful. So today we're gonna do uh we've got three main things. So we need to, I've been told we need to talk through M SE so how to do an M SE. Um and then we're gonna go over schizophrenia and think about an example M se. Um Then I'm gonna talk about some of the more common psychiatric conditions of the mood disorders and anxiety disorders and then finish with just a brief few slides on sort of the Mental Capacity Act and Mental Health Acts. Um, all of these three are really relevant for, if you're keen here for, oy, I think I had a station on every one of these things. So, really relevant. Ok. Mental state exam. Just so I've got an idea. Have you got, what do you guys know about mental state exams? Have you done them on people? Have you read about them? Um, have you, do you not know anything about them? It doesn't really matter cos I'm gonna talk through how to do it and what they work, but it would be nice to have an idea what we got. Has anyone had a go at a mental state exam? Ok. So Abigail has written history taking, what do you mean by that? Abigail? Do, do people know what an a mental state exam is? If not, I can tell you in detail, it's quite hard when you're not in front of me. So it's hard to see who's doing well. Here we go, done them from videos but not independently on a patient. So, Lucy already now has an idea of what to do. That's good. Ok. So I'll get the impression that you at least know, well, I'm gonna go over what they are and sort of how to do them now and then an example and then hopefully you should have a better idea. A day of assessment of a psychiatric patient. Yeah, exactly. So, a mental state exam is like any other exam. But it's unique, I guess cos you're doing it about what they're telling you. So, there's seven main bits to it. Uh The first one is appearance and behavior and it's their speech, their mood, their thought, their perceptions, their cognition and insight. Uh You just go through each of these seven things and say something about within these headings. So I'm gonna go through each one now. So first of all, on appearance and behavior, you don't need a medical student as well. When they walk into the rooms, how do they look, how are they dressed? How do they appear? Ok. And without being er, too judgmental, I guess you can literally just describe how they look. So that's really easy. After that, you move onto their speech. Um Three really basic things you can just say about anyone's speech is the rate the rhythm and the volume that someone speaks at. Um and that alone, if you're really thinking about an OSC will probably be enough cos it's a meaningful thing that you're saying about a speech. But if you sort of go in the extra mile, you can also suggest, is there some kind of thought disorder? So I don't know if anyone's heard of the term sort of pressured speech. So that's sometimes seen in mania and that's where you have this fast speech with irregular rhythm and irregular volume or sort of poverty of speech where there's I'm not really saying much which you see in depression. So it's a slow rate. But the main thing is you just need to make a comment about the speech and you can do that quite easily if you just comment on their rate, rhythm and volume of speech. The two sort of big ones that you need to go over are mood and thought. So mood has a few sections to it. The most obvious bit is just asking them to describe their mood. So an easy way of doing this is just asking how has your mood been or getting drunk at 110. But then you also need to give your opinion as well. Cos sometimes people will say a mood slightly different to how they're feeling. Um sort of quite funnily, this is called the objective opinion even though it's what your subjective opinion is. But so you need to ask about their mood and give your opinion as well. Another really important thing to ask is is there anything that they enjoy doing or when was the last time that they enjoyed doing something? So that's the really important psychiatric system of anhedonia, which is that people don't enjoy things. Then you need to ask about energy, have their energy levels been decreased, which you might see in maybe depression or anxiety or it might actually be increased, right? If someone has bipolar and they're in a manic phase, there's four important physical symptoms to ask about. So, sleep, appetite, concentration libido and you can just rattle through them. Have they changed? And then in this big red box, so, showing that it's really important, you need to do a risk assessment and that's a really brief risk assessment just working out. Um, whether they've got any risk to themselves or to others. Um, how you do this, I guess is dependent on the patient and the time frame that you're working with. Um, it can sometimes be quite a lot to go straight into asking someone if they've had any thoughts about taking their own life. And you sort of need to approach it in a sensitive way, quite a good way of doing that is to ask sort of quite broad questions to begin with and then build up to the more precise questions that you have to ask. So instead of going straight to something like, have you had thoughts about suicide instead? Like I've written here saying, how do you feel about the future? And then have you ever felt sort of hopeless or that life's not worth living? And then any thoughts about harm, harming yourself or thoughts about suicide? And then obviously plans are so a, a real red flag. Other things written here, if you do think that someone has a risk, is there any protective factors? So things like things they enjoy doing or Children and family or something that you think might be a protective family factor. And then again, as part of a risk assessment, it's not just sort of risks to themselves but a risk to others or a risk from others as well. Again, if you're doing an M se exactly how much you'll be able to get through a, sort of risk from others might be debatable, but you do need to do some kind of risk adjustment just checking about sort of self harm or suicide. It's quite important. Ok. Moving on. Yeah. So thoughts number four is the other slightly larger one. Um I guess it would vary on what, where you're reading exactly what you need to ask. But I think these five things are really good, an important specific delusions to do with the content of people's thoughts. OK? Um So whether people feel that some pe some psychiatric conditions lead to things called thought insertion or extraction or control. So that's where you think that thoughts in your head aren't your own, they're being put there or the opposite that are being removed and then sort of controls that someone can control your body like a puppet. There's also things called persecutory delusions. So that's where you feel like someone's out to get you and it's just written there. Exactly. It is. And then ideas of reference that you think that people on the TV street, whatever are talking about you when you're not So these are some key questions to think about and to be able to ask if you're, when you're doing your M se. So that's good things for thought. You also might need to think about the form of a thought. So that's you're seeing kind of relevant to the slide on speech where we had this slow and labored thought revealed through the speech and the pressure thought and that shows depression and mania, these are less, you'll notice if you're looking at these slides later or if you're reading through them. Now, these are sort of ideas that you pick up as you're taking your history. They're less specific questions that you'll be able to ask. Um if you're sort of doing an m se quickly on a patient that this might not be possible to get right to the bottom of these cos it's more of a full history that you're taking. So just make sure that you're really asking these sort of questions here, quite specific questions to do with the content of their thoughts. OK. We're racing through after you've done those two. It's reasonably simple. So you talk about perception and these are hallucinations. So, hallucination is where you perceive her to be something in the world without any external stimulation. Um It can be quite difficult to ask about these cos um the person perceives them as real. So an example of everyone is, do you ever hear things that other people can't hear such as noises or the voices of other people whispering or talking. Um, and I think that's a good way of doing it. It's not just, er, auditory, of course. So you need to also ask, do you ever get any unusual tastes, unusual smells? Um, and then again, for s for sights as well, so you can quickly work your way through them cognition. This is quite easy, you can do this really basically if you just ask are your instance, time place or person and most people should be. And if that's not the case, then you might need to use a more formal assessment tool. But time place and person is a quick way of going through that and then finally insight. So this is really important for differentiating different conditions. Um So for example, in psychosis, people might not have insight, they don't think that they're unwell, they believe these delusions that they have. And then in other conditions like er O CD, people recognize that the thoughts that they're having aren't good for them and aren't sort of shouldn't really be based on reality, but they can't help it and they, they want treatment. Ok. So insight. Do, what do you think's going on? Do you think that you need treatment? And that's a good way to end that? Right. So that is a rush through the M SE and I've sort of summarized them here. Does anyone have any questions about that? We All right. OK, good. So really basically you're gonna start their appearance and behavior. How do they look? Speech, comment on the rate, rhythm and volume. If you're feeling like you can, you can suggest some kind of form of thought disorder on mood, you need to ask what is your mood like and give your opinion, other things that you enjoy. Um physical symptoms, sleep, appetite, concentration, libido and their risk assessment and thought we've, we've talked about thought insertion extraction control. So people putting thoughts in your head, taking them out, being able to control you persecution. Do you ever feel like someone's out to get you and reference the people that talk about you and then perception, hallucinations, cognition, type place of person and an insight or opinion and engagement. So if you can just learn this basically and rattle through it, you'll be well on your way. Lucy asks, would you comment on rapport at any point? Where would you put that in? Ok. So I'm guessing what you mean is sort of how they're communicating with you throughout the conversation. Um I guess it would depend on the specific um part of rapport is, I guess quite a general thing. Like maybe you could do that at the start. So you could say that you've introduced yourself to the person and that they're um they appear engaged and that would sort of be part of the appearance and behavior. Um I think that would be quite a reasonable thing to say at the start. Num number one. but again, if part of the report is that you're unable to engage with them because they feel like they're so low in mood and they're sort of not wanting to talk, then that would maybe be part of your objective opinion of their mood. But I guess appearance and behavior, maybe part one would be a good place to put that good question. Lucy. OK. Let's briefly go over schizophrenia. Some of the main things. Does anyone know some of the symptoms of schizophrenia or sort of important classifications of symptoms of schizophrenia? What have people got it? Ok. Now's first rank symptoms at least is really that's very good. So I've actually got a slide on that in a second which we'll be able to go over. Those are some of the positive sy symptoms that gets through in you. Does anyone know what the other classifications of symptoms are? Right. Abigail says, illusions and hallucinations. OK. So illusions, that's a very first of all, yes, hallucinations are definitely a part of um schizophrenia and again, part of the positive symptoms, um illusions, I'm not sure about, I thought illusions were when there is an external uh stimulus that's being misunderstood. OK? And moody gets exactly what I'm after positive, negative and cognitive impairment. Nice one. Um So it seems like you guys know what you're talking about already. Exactly. So we've got positive negative uh symptoms and cognitive impairment and yeah. So positive symptoms of things like delusions and hallucinations and also these thought disorders, negative is generally sort of quite a flat or blunted emotion and characterized by withdrawal and then, yeah, exactly. There's cognitive impairment, good stuff. And now, as Lucy wrote, Schneider's first rank symptoms are some of these positive symptoms. Um these have been taken out at the diagnostic criteria, I think because they're not um as sensitive and specific as they were once thought to be. But regardless they're good things to have an idea about. So, auditory hallucinations are the most common type of hallucination in er schizophrenia and they're commonly discussing a person in the third person. Um but you can also get somatic hallucinations and that, yeah, we've gone over thought insertion withdrawal, broadcasting, uh this passivity thing and then yeah, delusions. So false meetings at attributed to things. And I've written the example of traffic light turning dead red, meaning that Martians are coming so completely nonsensical. Um So just in general, psychosis is a set of symptoms that cause someone to lose touch with reality, what else might cause a similar presentation? So if someone appears like they don't know what's going on, like what are our differentials of psychosis, can anyone suggest them? So if someone is presenting and they seem to ok, electrolyte imbalances, we just got it. That would definitely be something uh or I guess what might cause those electrolyte imbalances if we're gonna go 11 step up, ti a abigail suggests completely. Right. So, that could cause someone, er, to become confused, a serious infection. That would definitely be true. Um, if the person developed, developed delirium after it, medication or drug overdose completely. Right. So, certainly some recreational drugs. Right. They basically induce a psychotic state, um, drinking juice. So, Lucy suggests completely. Right. If you get more, put them in. But I've written out lots here. Yeah, brain tumor, Lucy certes completely. Yeah, liver issues. That could definitely if it was causing some kind of um encephalitis which has been written down here. So psychiatric conditions, it's not just schizophrenia, other things. So in severe depression, um that can lead to um sort of similar presentations, structural problems. Uh Someone's already said this brain tumors, dementia, dementia, it wasn't mentioned so that can make people very confused in older age, um then reversed to ovarian states. So encephalitis, acute confusion and then uh cushing. So that would lead to these electrolyte imbalances, but it wouldn't necessarily be the electrolyte imbalances that would cause the um the confusion. So other endocrine causes and then we've mentioned drugs, alcohol withdrawal, good. So you might wanna think about some investigations to include, exclude these things if someone's presenting with psychosis. And I've suggested some down below here. Good stuff racing through. How do you manage a psychiatric condition? I think um a really good thing to answer for all psychiatric conditions when you're talking to a consultant or doing your oy is to recognize that a full psychiatric history and sort of necessary investigations takes longer than the eight minutes you've got. So I'd say I'd like to do a full psychiatric history and do investigations to exclude an organic cause. Some of which we've gone over in the last slide. And then using this biopsychosocial approach to treatment is a really good thing to do to split it up. So deal with the biological, psychological and the social implications. And if you stretch your answer like that, you'll, you'll do pretty well and it will give you something to go off as well. So with the example of schizophrenia, obviously, antipsychotics are really important part of the treatment. Um I've written some of the examples of the common ones used here. If it doesn't work, you switch to a different one. And then third line cloZAPine is used. Does anyone know the important side effect or risk from cloZAPine? That's uh means that it's a third line drug amongst other reasons. But the common exam thing that people ask about what can cause a pain cause anyone there. Whilst people have a thing of keep moving on. So biological, then psychological interventions. So certainly in schizophrenia, neutropenia, yeah. So kind of it can cause agranulocytosis. So that's basically right. So it can interfere with how your blood cells are produced. Nice one. Lucy. So psychological family intervention uh will all renew. Um family intervention is a thing where family is involved to identify babies and solutions. And it has a really good evidence base in schizophrenia CBT, which will, is basically used for most psychological uh psychiatric conditions and then thinking about the social implications. So discussion of finance, housing and employment is really important in someone who might have episodes of psychosis. Um and then in making contact with sort of community mental health teams so that er care plans can be put in place. So this is the first we're gonna do a couple of these, of the management of different conditions. But you get the idea structure is biopsychosocial. So say something about each one and you'll have a good, a good answer. So as you quickly rattle through an example, M se in schizophrenia, so the patient would come in um this word Kemp or unkempt. People are constantly using in MS ES. So they appear unkempt and agitated and restless from rocking the speech. The speech is fast, irregular rhythm and volume and this person has even suggested that that might then be a pressured speech which is very good mood. Patient reports feeling normal hive seems agitated and they do not report hopelessness about the future or intent to themselves or others. So they've done this objective and subjective opinion and they've done a quick risk assessment which is good um Thoughts, they've mentioned the delusions that the person has. So that's about the content of their thoughts. And then also something about the thought insertion. So they've gone through the thought insertion extraction, broadcasting questions, perception, person's moving head and is distracted, appearing to listen to voices in the room and is unable to recognize this unchallenged. So this is quite a important point about hallucinations or perceptions is often the person is just thinking that they're real um and might not communicate them to you. And so it's up to you to sort of recognize that the person is distracted and that something else might be going on. Um And then the important thing I guess about hallucination is that it really is viewed as real to the person, cognition, time place and person and insight, they don't acknowledge the need for treatment. So these are just some examples of the positives that the person's found uh as you can see if you go back through the slides, there's a bit more to each one, right? How's your psychiatric history? Obviously, when you a full psychiatric history done by a psychiatrist takes a lot longer than seven minutes, I think it's an hour. Actually, when I was watching them, we set aside the whole thing and talk about childhood and everything. Um So the idea in an ay is that it's focused and uh I'm gonna tuck up tuck your wedding now. So you start with the presenting complaint and like, I guess you would with a physical symptom two of the really important things to find out are the timelines for how long this has been going on for and any triggers for it. So if it's recurring, what causes the, the symptoms. So I guess just for example, going forward with an, the example of anxiety, you'd wanna find out what's causing it. Um And how long it's been going for? Is it coming in waves or is it constant? So that would be for the tricks and timeline for any psychiatric condition or mood problem? Um You then need to ask, how do they feel and can they identify physical symptoms? So again, with the example of anxiety that would be chest pain, sweating, breathless, whilst they are anxious, ok, or depression, they might give a symp to like a physical symptom of a weight in their stomach or something. So you just need to explore their presenting complaint and ask about it and a good way of breaking that up is in this triggers and timeline and then asking you about how it feels. Remember to ask what else has been going on and keep wearing around. There might be more than one thing going on and it's important to identify all these different things. Um good then to sort of make it quite a focused psychiatric history, you can go through some quick elements of the M SE and these are just to screen for conditions quickly. So mood you might have already asked about that. But you could quickly ask about these physical symptoms that change during different mood disorders. So, how's their sleep appetite concentration in the medo changed? You'll notice the big, big, well, I guess I'll go over that in a second. Then these thought disorders, thought insertion extraction, broadcasting. Um this idea of persecution that someone's out to get them and their ideas of reference uh that people on the TV are talking about them and then quickly screening for any hallucinations. So, like I was gonna say in this big red box is the really, really important part of the psychiatric history, which is again, the risk assessment which is under mood for our embassy. Ask about their thoughts about the future, um, thoughts about harming or suicide. Uh, you really need to ask this in someone who's coming in with low mood especially, but in all psychiatric histories. Um, so make sure you do that in your, ask past psychiatric history. I mean, this is gonna probably come under your past medical history, just what di previous diagnosis and episodes about. And then, yeah, drink history as, as usual, right? Let's quickly go through depression. Ah, I was gonna ask you to name some of these symptoms, but here it is. So the phd nine is the tool that's validated for nice in primary care. And if you read through them now you'll see that basically all of them if you do a focused psychiatric history with bits of M se and you'll ask about it anyway. So, depression, that's, that's about their mood and her is their enjoyment of things and energy, sleep, appetite, concentration you'll ask about. I put the Lido in brackets cos it's not part of the P HQ nine, but there's no reason why you couldn't ask about that and then your suicide risk assessment as well. Some other things in there is this feeling guilty or worthless and also quite an unusual one talking or moving slowly so that people notice all the opposite. Ok. So these are some of the key questions to ask. But I guess the point I'm getting trying to get across is that if you have a good structure to your history, you're, you should identify most of these. Anyway, the management of depression again broken up into biopsychosocial. So really simple things that are good for everyone, but especially people with depression here. So to encourage physical activity, reduce alcohol intake, improve sleep hygiene, you can direct them towards sort of resources to help with that. These are things to do with your body that will make you feel better in your mind and addressing comorbidity. So people with depression might have concurrent diagnosis which aren't well controlled and which are contributing. If you're on the nice guidelines, you'll see the antidepressant depressant therapy is indicated based on how severe the depression is has one sort of factor. And also if the patient wants it or chooses it. So it's just raising that as a possibility. Psychological intervention again is dependent on how severe the depression is. So simple things. There's self help which are like these online resources that people can use, which are guided or not guided um to learn more about what they can do to improve their condition, group sessions. And then for more severe depression, it would be CBT and social directed towards the mind website or social groups, support groups that can help. Ok. Bipolar disorder. Moving on. Uh, so I'm gonna ask a question in a bit. So what are the two types of bipolar disorders? Does anyone know that check that people are still doing it? So there's type one and type two. Does anyone know what determines each one? Yeah, let's see. Ok, I'm gonna put you out of your misery soon. Very cool. I think it's on this next slide. So we'll see. Ok, you'll see, you'll give it to find out. Um, so bipolar disorder is characterized by these episodes of elated or raised mood. Type one has me manic episodes and type two has hypermania poua. Yes, you're completely right. Lucy, you've got at the, er, at the essence of it there with severity, I guess, but they are technically actually just have slightly different underlying to it, but you've hit the nail on the head there. So mania, what is mania? It is episodes of elated mood or irritability with increased energy for at least seven days. OK. So e everything in that is quite important to its definition, as you'll see when we go over hypermania and sort of crucially, it needs to also affect their function in some way. So how they interact with the world or their job, it can present in different ways. But common things I've written down here. So decreased need for sleep, more talkative, more impulsive, so more risky behaviors been done like spending or gambling or whatever. Um delusions and disinhibition. Ok. So you'll see that hypomania is different and it, I see what you mean. Lucy, it kind of does appear like a less severe form of main your own in a way. So it's only has to last for four days and it doesn't cause the same sort of functional social occupational impairment as many of us and then put it bipolar is that it's so then in conjunction with these depressive episodes. Ok. So type one mania and depression, type two hypomania and depression. That's the difference management, don't worry, biopsychosocial. So the uh pharmacological management of bipolar can be a bit complicated. So one important thing is that antidepressants like SSRI s, the common ones actually can make bipolar quite a lot worse. So that definitely needs to be reviewed. If someone's on an SSRI and bipolar is suspected, then obviously for psychosis, antsy er for these manic episodes, sorry, antipsychotic treatment is commonly used. Um and for the depressive episodes there's some different drugs that you used. I've written them down here, whether you need to sort of be able to recite these perfectly, these are probably specialists, uh medications and combinations that are being used. Um, what is important to know is that prophylactic treatment is with lithium? So you'll see if you go on the GKI medic site that there's a lithium counseling as a potential ay station that, that comes up cos has things to do with it's monitoring and things. So that might be worth looking over psychological again, talking therapies such as CBT social, making a lasting power of attorney. So these are someone who makes decisions when you don't have capacity um to do with your health and finances. Uh Thinking about financial management again, that's important because during these periods of elated mood, when there's this inhibition, that can be an issue. And then, yeah, a referral to the community mental health team and a care plan. Good. We are racing through anxiety disorders. Yeah. So I've just written this out again, basically what I've gone through for the anxiety disorders when you're suspecting anxiety again, it's triggers and timeline, the physical symptoms we've mentioned already. And then just thinking about what is the thought that brings on these physical symptoms. So if it's er, nothing in particular and they're feeling anxious all the time about most things, right? That might be a more generalized anxiety. But if it's uh the thought of a very specific objects or place or thing that's maybe more of a phobia. OK. So it's a way of differentiating the type of anxiety disorder and then thinking, what are the consequences of this thought and the behavior it leads to on their life and on their behavior. It's end of unusual stuff. Elements of embassy, like we talked past psychiatric history. Some of the, I mean, this was my OY station last year with someone with Gad. So it's a persistent anxiety or dread disproportionate to any risk in causing impairment. So, um it leads to these really common symptoms that people, I'm sure we all know about if you're, you're feeling anxious, importantly, it's not explained by anything else. So you need to rule out other causes. Panic disorder is different. So this is recurrent and unexpected panic attack. So it's more isolated and this is the palpitation, sweating, breathlessness. So it's quite acute and at least you're having concern about additional attacks or worries about the implications of the attacks or because someone has this panic disorder, they might stop doing certain things that they know lead to these panic attacks. Ok. No one panic, we will do biopsychosocial for these two as well. But just know that for Gad, there's like this step up management to do with what which psychological intervention you're taking. So the the initial thing if someone presents the GP with quite mild generalized anxiety disorder, um it might be enough to just communicate the diagnosis and to point them towards resources on the NHS website and think about monitoring them slightly more moderate. Um gad will probably benefit some from these er, self help and they can be facilitated or non facilitated or guided self help resources and they also can be online. And then past that once these have been tried these more sort of conservative approaches, um it's about using medication that's commonly an SSRI and CBT is really important and if it's really severe, it's referral to for specialist input. But back to biopsychosocial bio always gonna be important. Sleep hygiene, exercise, thinking about alcohol and caffeine intake. We talked about the drug treatment if it's indicated and SSRI S are first line of serotonin. Yeah. You know what SSR is psychological, a low grade psychological intervention or a high grade auth indicated. And then again, a simple thing to do is support groups for the social aspect. Ok. I hope that makes sense. Oh, it's just a thing on specific phobias here. Um Yeah. So like I mentioned before, this is where there's persistent fear or anxiety. So that's the sort of uh physical symptoms that they're feeling. But instead of being about generalized things, it's about a specific object or situation. And then because of that the patient will avoid um that object or situation as is the case with quite a lot of psychiatric conditions, a component of it is that it needs to cause distress or impairment in their actual functioning in social or their job. And again, it's not better explained by another disorder which I guess is reasonably self explanatory. The management is pretty similar, but an important thing to that I've written down here is that exposure response therapy can be used for these phobias, whether it's really in the name that you're gradually exposed to the thing and learn to overcome it. Ok. So in the last five minutes, we're gonna briefly go over ethics. Um So the Mental Pro Act, the Mental health Act and then uh those of you who want, who want a chance to uh really sensations can do it. So this is how you assess capacity. I wonder if that was the best order. Let's do what is capacity first. So people who lack capacity um are basically unable to make decisions for themselves. Um no, can be due to many things, but some examples here, if someone has really severe learning disabilities, um they might have a brain injury, they might be unconscious, right? Because they've drank too much. And that will mean that there's a medical decision that you think has to be made and you're unable to um discuss it with them and get their opinion on what they think they want. And so a decision sort of has to be made for them. And the mental capacity Act is used to empower or protect individuals who can't make certain decisions for themselves. So you have to make it for themselves. So a really important thing is that it's assessed in relationship to each decision. So some people can have capacity to make certain decisions whereas they might not be able to have capacity to make other ones. So someone with dementia may definitely be able to tell you like it's something really sim like whether they want a cup of tea or not, but they might not be able to make a really complicated decision about a sur surgery. Ok. Let's go back to how do we assess capacity under the MCA? So there's two stages. The first is you need to show that there's an impairment of brain functioning in some way. And again, that will be a cause like this going on and then you need to do a functional test. You need to show that the person can't, um, make a decision because of that impairment and that has these four really important parts to it. So they, you need to show that they can, in order to have capacity, the person needs to understand the decision. They need to be able to weigh up the pros and cons, they need to weigh that, er, retain that information long enough to, to weigh it up as well and then they need to be able to communicate it back to you. So there's four things that are really important, uh components of testing capacity. Ok? We've talked about that, then there's five main principles. So everyone's presumed to have capacity um until you suspect that they don't. And then it's specifically tested, right? So you don't just write people off as not having capacity, you need to show that they don't. Um if someone doesn't have capacity, you should do what you can to make. Um That's the bad way of phrasing that you should do everything you can to help someone make a decision is sort of the part of the menu of number two. So if there's something you can change, uh, so for example, if someone is drunk and they can't, they don't have capacity to make a decision. Um, you might be able to wait a few hours and then they will be able to make the decision for themselves instead of just plowing ahead with some surgery. So if that's possible, you should support them to make the decision themselves. Number three, unwise decision. So if someone's shown to have capacity, they're allowed to make decisions that you consider to be unwise. That's not a component of having capacity is not dependent on whether, um, the doctors think it's a good or bad idea. All they need to do is show that they're doing these four things that they're understanding, weighing up, they've got a reason for what they're doing and that's enough. It's not our place to decide what people should or shouldn't do. If someone doesn't have capacity, you should make the decision in their best interests and it should be the least restrictive thing. So, if you have multiple options, you should be doing a thing which has the least impact on them and it's the least invasive. Uh, good. Let's just finished in the last couple of minutes with the Mental Health Acts. Um, most people in hospital have agreed to be there. Right. But there's some people who have specific psychiatric conditions who really need assessment treatment and because of that sort of detention uh without their agreement, um And that's where the Mental Health App can be used. So I always sort of think about it. It's quite, it's more specific piece of sort of actual leg legislation that can be used to do specific things in certain circumstances when people have a psychiatric condition and there's some important sections that you should know about them because you might have to explain them in an sy or you might have to uh well, you should know about them for every reason but relevant to your exams, you might have to explain in a year or they come up on progress test or your multiple choice questions as well. Um What I've written on this slide are just four key points for if you're explaining mental health to someone, it's sort of the reason for why it's used the fact that there needs to be a treatment available if you're gonna detain someone and that patients can appeal uh the decision um and that's at a mental health tribunal. So my different hospital, we don't have much time. Maybe we start one more question. Let's just, I'll just tell you about these sections now we can finish. So section two, that's a section for admission and that's for 28 days for assessment. Importantly, that can't be renewed. But once someone is in the hospital, um you can then use section three which retains them for up to six months for treatment. So an important part when using these sections is the knowledge of what it requires. And for these two, here it requires two doctors. So one is the section 12 2 doctor which is a, so a doctor who's a specialist in these men in this mental health. One is just a doctor who knows the patient. And then the third one is this uh AM HP which I always forget what that stands for uh approved mental health practitioner. I think. So it's these three people, two of them are doctors and one is the AM HP. Um There's also section four which is can be used if you only have one doctor, right? Uh Gift to ask the question in terms of explaining your management to the OSK examiner should always mention that we would assess patients mental. Should we always assess? Should we always mention that we would assess patients mental capacity? Um I think that would be dependent on the situation. Probably um if someone comes in, uh if you're in an AK and someone has what you think is maybe quite moderate uh anxiety, generalized anxiety disorder, certainly in real life, you wouldn't have any real needs to assess their capacity because of that. If it was more severe, it would be, um then it might be something that you'd need to be doing. Um sort of to answer your question, I guess. No. So when assessing mental capacity in terms of explaining your management, that's not a common thing. It's not something I did in my oy and not something that they said was needed. Probably if you did throw it in it, it might not hurt you. But no, I don't think that you need to be talking about capacity when you're explaining management of different conditions or certainly not for all of them. I hope that answers your question gift. OK. Section two, section three, we talked about section four good stuff. Then we've got this thing called holding powers. So that's for people who are already in hospital. Ok. So this is for admission, it's for detention. Um So that can be 72 hours by a doctor and six hours by a nurse. And you'll notice that that can just be done with just that doctor or nurse. It doesn't need the second doctor or a HP. It's just used to stop the patient leaving until one of these more formal assessments can be done. So probably a section two. So why that 72 hours, I guess is the example is if it's a Friday night and it becomes unclear when a more formal assessment will be possible. It might by the Monday that might need to be 72 hours. Uh No, we don't need to go backwards. We need to go forwards and then police powers. There's these two sections. So police also have some power within the Mental Health Act. That's to bring someone from home into a place of safety or to bring someone from public into a place of safety. Does anyone have any questions about any of that? I think that's basically it for me. Oh, very nice. So just thank you if you're having to explain the mental health that you'll probably need to talk about why it's necessary. So most people have agreed or volunteered to be in hospital, but sometimes I think there's psychiatric conditions that interfere with that. Um You then need to explain which section you're using, I guess commonly it would be section two which would come up in an OSC. And that's because it might be the sort of the first interaction that the patient and the family have had with um mental health team past that probably the patient and family will have a better idea of what the mental health Act is. And then yeah, just explaining this because we need a treatment and that should be begin given to the patient and that it can be appealed, right? I think that's it for me. Thank you very much. Uh There is no QR code. So sorry, my wife, I cut off there. I've only just joined back. Um but thank you very much Ben for that. That was really informative. Um So yeah, just scan QR code and get the slides. Can I just get the people who are planning on staying for OY practice to put a Yes in the chat. Do you have? I've realized I didn't get sent a QR code for them to send their feedback. Do you have like a link to it? You could post in um the feed. So the feedback gets emailed automatically anyway. Um As long as you just fill it out, you'll get the slides. So, yeah. So is that for people who are doing the moy practice? Um So the facilitators are um Ben, you're a facilitator, aren't you? Uh I don't think so. No, I looked at the, no. Ok. Um In that case, uh I think it's meant to be Isaac who's here, Isaac. I don't know if you wanna introduce yourself. Yeah. Hi. Yeah, thanks, Ben. That was a great presentation. I'm another fifth year at Manchester. Ok, great. And then um I think agenda is meant to, I think he might already be in his uh breakout room. Um But as far as the people who are staying, oh, sorry, Lucy, sorry. Can you just repeat, how do we get the slides? So you automatically get emailed the feedback and then you just need to fill that out and then you'll get the slides sent to you. Ok. So for the people that are staying, um Yeah. All right. So maybe Puja Banu Abigail if you join Isaac's breakout room and then gift Moody and Janette. If you want to join gender's breakout room, I will try and pop in and out of the breakout rooms just to make sure that there are actually facilitators in them. But yeah. Ok. Thank you everyone. I've enjoyed it. All right. Thanks, Ben. Thanks.