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Psychiatry for the ISCE

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Psychiatry for the ISCE

  1. 1. Psychiatry for the ISCE - Notes Dr Jason Hancock Academic Clinical Fellow in Old Age Psychiatry Psychiatric history; Introduction, how long we have, what we are going to do. PC/ HPC – imagine you are asking about pain. How is HPC affecting your functioning? Work, day to day life? Past medical and psychiatric history; previous mental health problems, every needed medication, every needs hospital admission, every needed MHA? Medications; allergies Social; who do you live with, work? Hobbies and interests? (how is this affecting your day to day functioning, if not already asked) Alcohol, smoking, illicit substances (and legal highs) Family history of mental illness Must ask about history of and current thoughts of self harm and suicide, every time. Mental State Exam; (Taken from ISCE mark scheme) Appearance and behaviour; how dressed (mania), mention obvious things, rapport? Speech; rate and form, how fast? Any evidence of a formal thought disorder (flight of ideas versus loosening of associations). Mood; subjectively they report…… Objectively they appear…. [mood versus affect]. Perception; do they report hallucinations (auditory, visual), where they responding to hallucinations? Thinking; any evidence of delusions, any thoughts of self harm or suicide? Cognition; orientated in time, place, person? Insight; what do they think is going on, do they think they are mentally unwell? Mania; History/ MSE;  Mood, for how long, when did it start?  Activities; can you concentrate, find your thoughts racing?  Energy and sleep.  Risky things; money, gambling, drugs taking, sex.  How is this influencing your life; partner, family, work.  Thoughts self harm/ suicide  Evidence of psychosis; (mood congruent) special powers, a special mission, hallucinations… Management;  Biological;  Acute treatment of mania; antipsychotics (olanzapine), or mood stabiliser (Lithium, Semi-sodium valproate (Depakote), +/- benzos (diazepam).  Longer term stabilisation; Lithium or Depakote (or antipsychotic).  Psycho; longer term use of psychoeducation to recognise relapses, CBT.  Social; support for overspending.
  2. 2. Depression; History/ MSE;  Mood; how long, how would you rate, time of day.  Activities; any enjoyment (anhedonia), concentration.  Energy and sleep; when is sleep worse.  Appetite and weight loss.  Guilty (about the past), worthless (in the present), hopeless (about the future). That must be tough…..  Self harm/ suicide.  How affecting life.  Evidence of psychosis; (mood congruent), nihilistic delusions (parts of body dead), responsible for a terrible crime, hallucinations.  (Evidence of agitation or anxiety). Management;  Biological; antidepressants for moderate to severe depression (SSRIs citalopram, sertraline, fluoxetine first line, mirtazapine/ venlafaxine second line). Take several weeks to work (longer in elderly) and should be continued for at least 6 months after fully treated (longer on elderly).  Severe depression (resistant or life threating); ECT.  Psycho; Good evidence for CBT in mild- moderate depression  Social; other support, housing, employment etc. Anxiety; History/ MSE;  Generalised Vs specific (of what, phobias?) +/- panic attacks.  Symptoms of anxiety;  Autonomic; Racing heart/ palpitations, sweating, dry mouth.  Physical (chest/ abdo); SOB, chest pain, problems swallowing, abdo pain, diarrhoea.  Cognitive; fuzzy head, fearing you are going to die, depersonalisation, derealisation.  Do you have it all of the time? What brings it on?  Do you have panic attacks; racing heart, hyperventilating, fear loosing control, dizzy, tingling in hands and feet.  How is it affecting your life/ work?  What do you do to manage this (drugs alcohol etc).  Depersonalisation; everything around me is real, I am unreal (like a puppet).  Derealisation; I am real, but everything around me is not. Management;  Biological; Avoid benzos diazepam for panic disorders, can be used short term (2-4 weeks) for generalised anxiety disorder. Antidepressant (SSRI – citalopram/ sertraline) can help.  Psychological; CBT.  Social; will depend on individual cases.
  3. 3. Psychosis/ schizophrenia;  First rank symptoms;  Hallucinations; voices talking arguing (third person), running commentary, thought echo.  Thought alienation; insertion, withdrawal, broadcast.  Passivity phenomenon; mood/ actions being controlled.  Delusional perception; following a delusional mood. History/ MSE;  What has been going on? Open question….  Explore that… Then when you have a good idea of the problem identify the specifics…  When did this start, how did you realise it was happening (delusional perception), how do you know this is happening  Is this a fixed belief (delusion)  Have you found that you are hearing voices when there is nobody else around, or seeing things when there is nobody else there (hallucinations)  Has anybody been interfering with your thoughts (insertion, withdrawal, broadcast, blocking) (Thought alienation)  Has anybody been able to control your body, actions or emotions in any way? (Passivity phenomenon) Management;  Biological; Antipsychotic medication (atypical antipsychotics; olanzapine, risperidone), treatment resistant schizophrenia (Clozapine).  Psychological; CBT in psychosis (to prevent future relapses), family work/ education to reduce high expressed emotion.  Social; Support for work, housing. OCD; Definition;  Obsessions; ideas/ thoughts/ images that enter your mind (that are your own) even though you try to resist them, they are unpleasant and distressing.  Compulsions; are behaviours which are performed to reduce the distress associated with the obsession, are not pleasant but bring relief, often pointless (such as turning the light on and off 30 times) and recognised as so by the patient. History/ MSE;  (Obsessions); What thoughts are you having, do they come back even if you try to resist, are they distressing, what can you do to reduce the distress?  (Compulsions); do you feel compelled to act in certain ways, such as ….(see examples), what happens if you try to resist, have you ever been able to resist,  [examples; checking or ordering objects, washing hands, special behaviours – turning lights on and off, hoarding, superstitions]  Severity questions; how does this affect your life? Management;
  4. 4.  Biological; SSRIs can help (fluoxetine).  Psychological; CBT.  Social; will depend on individual circumstances. The Mental Health Act  An individual can be detained under the MHA is;  They are a risk to themselves or others  Are suffering from a treatable mental illness.  Are not willing to come into hospital informally.  Section 5(2); temporary holding power used by doctors (a single fully registered doctor) to prevent informal patients from leaving hospital (not ED departments) for up to 72 hours to allow a more comprehensive assessment (full MHAA).  Section 2; a section by AMP (social worker) and two approved doctors (at least one section 12 approved psychiatrist and the patients GP). For assessment, lasts 28 days.  Section 3; a section by AMP (Social worker) and two approved doctors (at least one section 12 approved psychiatrist and the patients GP). Lasts up to 6 months, for assessment and treatment of a mental illness.  Section 5(4); temporary holding power by a mental health registered nurse to prevent an informal patient leaving hospital for 6 hours, or until a doctor can come and consider using a section 5(2).  Section 136; used by police officers to detain people acting in a ‘strange way’ in a public place.

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