Karen Notes Psychiatry

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PSYCHIATRY Taking a psychiatric history: ENSURE confidentiality IF uncooperative: I understand that you are going through a bad time but please help me if you want me to help you. HPI: when? How? Worsening or getting better? What is the effect on your life because of the symptom? symptom? What is the effect on your sleep? Mood: How is your mood? Have you noticed any change in your sleep (in depression: early morning awakening; anxiety: difficulty initiating sleep)? Change in appetite? Change in weight? Did you experience any weight loss or weight gain (typical: vegetative sx go down; atypical: vegetative sx go up); What is your energy level? Do you think life is worth living? Have you thought of harming yourself or anybody else (What, when, how)? Are how)? Are there times when your mood is high?  anhedonia: loss of interest in activity which o used to be pleasurable. Psychomotor retardation: more common in o depression than agitation Psychosis: I’m sorry if I have to ask questions which may sound silly but I will need your cooperation. Do you see/hear/feel things which others do not? Did you have any strange experiences? Do you think somebody is putting ideas in your head (thought insertion)? Do you think your ideas are being broadcasted everywhere/do you think people are after your ideas (thought broadcasting)? Do you think that people, TV, radio, newspaper is talking about you? Do you hear voices telling you to harm yourself/somebody? Insight: Do you think something is wrong with you? Do you think you need help? Judgment: What will you do if there is a fire in this room? What will you do if you find an envelope with a name, ticket, everything? Cognition: do you know who you are? Where you are and the time? ORGANIC DISORDERS AND DEMENTIAS Lifestyle Stress Case: Margaret aged 35 years presents to your surgery on a busy afternoon. She tells you she had about 6-8 weeks of ongoing fatigue and tiredness. She denies any specific symptoms but describes just fatigue, weariness, and feels as cannot get out of her own way. Margaret is not your regular patient but attended surgery on few occasions and you know she had changed a couple of jobs but now tells you she is working at 3 different places everyday starting from 8-7pm. She was in a relationship but broke up recently and at present is living with her extended family in suburban area of the city. Margaret is smoker for the last 15 years and on average smokes about 15-20 cigarettes per day  and  and drinks 3-4 standard drinks of red wine every day . She takes ASA for her occasional tension headaches and takes no other OTC or prescribed medications. she had not other significant PMHx. Margaret describes some stress at work and finds hard to cope with the manager at one of the jobs but still she is carrying on. She requests you to prescribe her some medications for her stress and mentions that few years ago one of the GPs of same practice described her antidepressants medications which she used for some time and thinks that maybe she needs those meds again.

Task a.

How will you manage Margaret (lack of sleep, good appetite, no early morning awakening, mood is okay, no psychosis)

History -

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Consent I understand that you have tiredness and feeling fatigue, can you tell me more about it? Do you have any weather preference? Do you have palpitations? Light-headedness or dizziness? SOB? Chest pain? Weight loss? Night sweats? Headaches? Any lumps and bumps on the body? Any cough? Any tummy pain or change in waterworks or bowel motions? I understand you smoke and drink alcohol, have you tried using illicit drug use? How’s your mood? Has there ever been a time when your mood was very high? Any problems with sleep? Weight? Appetite? Do you still find things pleasurable? Do you think life is worth living? Have you thought about harming yourself or others? I understand you were prescribed antidepressants before, do you know why it was given? Psychotic symptoms: Do you feel/see/hear things that other do not? Do you have any strange experiences? How’s your general health?

Management Consider quitting one of the jobs Consider moving out of the house DO NOT prescribe antidepressants Lifestyle modification Healthy diet o Regular exercise o  Address alcohol and smoking o Meditation and yoga Refer for stress management  Acquired Brain Injur y and behavioral behavi oral changes Case: You are working in GP practice your next patient is a health worker who looks after a house accommodation disable people. He is here to talk to you about James who is one of the residents of the house. James is 37-years-old and living in this house for a long time. He has a down’ down’s syndrome. He had a head injury which required surgery when he was young. And then his family put him in this house as he needed a lot of support. He is also having epilepsy which is well controlled with the medication. The health worker is here to talk to you about James’ James’s recent change in behavior. Task a. b.

Talk to the health worker, Tim Management

History: He was shouting at other residents and slams the door. He hardly talks to anybody. Family talk to him but didn’t  come.  come. He respond but doesn’t  want  want to talk to anyone. No fever, Used to work. From last 4 weeks he cannot get up in the morning, become very abusive. Nothing happen at work. Features: -  Acquired Brain Injury: An y type of the brain dam age that occurs after birth. The brain injury happens in two ways: Sudden onset: trauma, infection, lack of o oxygen to brain. (Near drowning), Stroke. Insidious onset: prolong alchol and o substances abuse, tumor or degenerative diseases. How does it affect the person? person? Long term o effect of ABI are difficult to predict. It’ It ’s different in different people, the patient can

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present with behavior and personality changes. Thinking and learning abilities. Increase fatigue. History -

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Can you tell me more about what happened? He is violent, verbally abusive to staff, socially isolated, he doesn’t want doesn’t want to talk to anybody. They used to go to work, but last 4 weeks he doesn’t want doesn’t want to go to work. How’ How’s his mood? Anhedonia? Sleep? Weight?  Appetite? try to self harm himse lf or somebody somebod y else? No he doesn’t. doesn’t. Psychotic symptoms:Talks bizarre? Delusions? See/hear things others do not? Family support? SAD I understand he had brain injury years ago, do you think something has happened recently (No)? How about his epilepsy is it under control (Yes)?

Management: -  Alright Tim, I’I’d like to see James. I’I’d also organize psychiatrist. I’I’m concerned that the personality changes might be because of the acquired brain injury when he was young/in the past. We need to organize some investigations. For example CT head, urine drug screen, other blood tests. Can you give some medications for his behavior now? No, not at this stage, psychiatrist needs to see him first before give him medications. I’d I’d like to involve the family. If he has self harm we need to admit him. Psychiatric Patients Get Sick Too Case: A 40-years-old man comes to ED in a district hospital where you work as HMO. He had chronic schizophrenia for the last 20 years and now complains of pain in the chest. The tertiary care hospital where psychiatrist is available is 200km away. Task a.

b. c.

History (chest pain since last 2 days, all over the chest 4-5/10 in severity; not taking medications for the last 1 year; I can see my girlfriend constricting my chest and back; my dentist has inserted a magnet into my tooth to spy on what I’m doing; no suicidal ideations; lives alone and nobody to take care of him) Physical examination (normal) Discuss diagnosis and management

History -

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Is my patient hemodynamically stable? Confidentiality May I know a bit more about the chest pain? Since when? Where exactly how severe is the pain? Do you need any pain killer? What is the type of pain? Does it go anywhere else? Is it for the first time? Did the pain come with nausea/ vomiting, sweating, anxiety? Does it come with any activity or walking? Do you feel any SOB, any racing of heart? Any pain associated with chest movement or breathing? Any recent URTI or fever? Any injury or trauma to your chest? Any heart burn or tummy pain? I understand you had schizophrenia for the last 20 years, are you taking your medications regularly? When did you last see the specialist? What medications were you on? Why did you stop your medications? Any side effects? I would like to ask you some routine questions, do you see/hear/feel things that other do not? How is your mood? Any change is your weight, appetite, or sleep? Do you think life is worth living? Have you thought of harming yourself or others?

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PMHx: any history of heart condition? Hypertension? SADMA? Whom do you live with? Do you have enough support?

Physical Examination General appearance Vital signs Chest and heart examination Diagnosis and Management I would like to admit the patient in the hospital now. For the chest pain, we will do ECG and cardiac enzymes and take blood for baseline investigations. I would call in the medical registrar for further assessment to rule out any organic cause. Secondly, he may have relapse of your schizophrenia because he is not taking his medications and he has nobody to take care of him at home. Based on these, we’ll arrange for transfer to tertiary hospital for psychiatric assessment and management. Dementia of Alzheimer Type Case: A 35-year-old lady comes to your GP clinic asking about her father who has recently been diagnosed with Alzheimer disease. She is very concerned about her father and has many questions from you. The daughter has the father’s permission to inquire about his condition. Task Explain about Alzheimer disease -  Answer her question Counseling What is Alzheimer disease? disease? It is a type of dementia where there is wasting of brain cells which in turn affect the function of the brain. The early features of this disease are: short-term memory loss (esp recent memory o where the person cannot remember what has happened a few hours ago or even moments earlier but may clearly remember the events of the past) progressive decline in cognitive/mental o functioning Unfortunately, it can worsen slowly with time and can lead to behavior changes and severe memory loss where the person might even forget the names of family members. It may also lead to self-neglect that can further proceed to accidents at home or outside and poor nutrition. Is the diagnosis 100% sure? sure? It is a diagnosis of exclusion. It is only after excluding the correctable causes that we can diagnose Alzheimer disease. We might see some changes on the CT scan of the brain. However, the definitive diagnosis can only be known after the person passes away and examining the tissue of the brain under the microscope is done. Can it be depression? depression? Depression by itself can produce dementia and it is called pseudodementia. It is important to exclude it before diagnosing dementia. On the other hand, people with Alzheimer disease can have depression, especially in the early stages of the disease because they can recognize their disability. Do not worry so much. I will be visiting your father and assess his condition and he will also be assessed by a psychiatrist, and if required, will be given medications for depression and he will also be followed-up on a regular basis He will be assessed by age-care assessment team. This team is composed of geriatrician, occupational therapist, physiotherapist, social worker, myself as a GP, psychologist and psychiatrist. The role of this

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team is to assess your father’s condition, level of dependency, and eligibility for services that can be offered to him. Geriatrician might prescribe some medications that can delay the progress but will not treat the illness. Occupational therapist can assess the home situation and his needs (eg fix lights, put railings, remove loose carpets, etc) to keep your father safe. The social worker can arrange meals on wheels if required, help him in washing the clothes and cooking food, and can organize social support. Physiotherapist will assess his ability to walk and might provide him with walking aids. Psychiatrist will assess his mental state and prescribe some medications. Is it better to put him in a nursing home? home ? The agedcare assessment team will decide on it after assessment and the options available are: To stay home if he can cope (preferred o option due to familiar home environment). He will be assessed regularly by team. Living in the nursing home where a nurse o will take care of him and I will also visit him regularly If at any time you want to take him back o home, you can do that and you can have access to respite care. It is a type of care given by trained people on a temporary basis that help you take a break and have some rest. His vision and hearing will also be checked and his license may be suspended. It is very important for his safety and wellbeing. Will I get Alzheimer disease? disease? It cannot be said at this moment although there is a rare type of Alzheimer that runs in families and occurs at an earlier age. But because there is no family history, it may not be possible. However, the specialist can explain more about it.

Due to poor Recall and Registration, patient might have  Alcohol-Induced Brain Injury Wernicke-Korsakoff Syndrome Vision : Ophthalmoplegia -  Ataxia Memory Impairment (Amnesia) MMSE -

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I will do MMSE which is a screening test to assess your cognitive or mental functioning. It is a simple test that includes questions that assess you in a number of areas and has thirty points in total. It will take approximately five minutes and I will guide you through it once we start. If you have any problem or questions, please please don’t hesitate to stop me. Can we do the MMSE? Doing the MMSE.....(+) problem on registration and recall. It can be Alcohol-induced Brain injury because of chronic alcohol abuse. It can also be WernickeKorsakoff Syndrome. What are you going to do with this patient ? (by Examiner) I will do complete medical evaluation and refer to psychiatrist for further neuropsychological testing to exclude more diffused impairment like dementia. Critical Error: Failure to identify short-term memory deficits; and a response that patient is delirious or demented.

CASE 109 Teaching Folstein MMSE Case 1: You are a resident in Psychiatry Department. A 28year-old was admitted with severe depression who is currently taking SSRIs. She is a secondary school teacher. A final year medical student did an MMSE and wants to discuss the results which he shows on a small piece of paper.

Performing MMSE (Bookcase Condition 146) Case: A 50-year-old barman comes to the GP clinic. He has a history of consumption of up to 10 standard alcoholic drinks over the last few weeks. His wife told you that he is quite forgetful and unreliable for some months. You have completed the history and now proceeding to test his cognitive function. Task: a. b. c. d.

Do MMSE Explain what you are doing and why Summarize to the examiner the normal and abnormal MMSE findings Interpret the results to the examiner including what conditions these results signify

MMSE RESULTS of the patient: problem on registration and recall therefore patient has short -term memory) ORIENTATION 5+5/10 REGISTRATION 1/3 (3 tries) -  ATTENTION AND CONCENTRATION (5 /5) RECALL 0/3 LANGUAGE Name two objects (2) No, If's and or but (1) ask patient to close eyes (1) write a sentence (1) hold paper with right hand, fold into half, put on lap (3) CONSTRUCTION draw diagram (1) Patient is most likely not delirious because of intact orientation. (Critical Error: if you say patient is delirious) Delirium is disorientation....

Case 2: You are a resident in a large teaching hospital and you are asked by a final year medical student to teach you MMSE and wants to discuss the results. Orientation 5+5/10 Registration 0/3  Attention and Concen tration 1/5 Recall 0/3 Language 2+1+3+1 = 7/9 Did not write the sentence and copy the diagram : gave up Total 18/30 Tasks: a. Explain the results b.  Answer the questions that tha t the student asks you

MMSE (ORARLC) (total of 30 points) Orientation (total of 10) 5 points: Year, Season, Date, Day, Month, o 5 points: State City Suburb Hospital Floor, o Place Registration (Immediate Memory; Total of 3) Say three things and ask patient to repeat o Patient recalls three things o Patient can go for 6 tries o -  Attention and Concentra tion (total of 5) WORLD Spell forward and Backward o (easier to do and less time-consuming) or Subtract 7 starting from 100: o Recall (Short-term memory; Total of 3) Reproduce three things that I have told you o a while ago

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Language Name two objects (2) o No, If's and or but (1) o  Ask pt to close her eyes (1) o Can you write a sentence for me? (1) o Hold paper in right, fold it into half, put it on o your lap (3) Construction Draw Diagram: Two overlapping hexagons o which are side by side (1) checks neospatial orientation Depression may have pseudo-dementia o

MMSE Formula : ORARLC Dementia: earliest symptom is lost of short-term memory Registration and Recall is hallmark of dementia Delirium: has poor orientation, something acute and patient is confused; auditory hallucinations.... Patient came in with 18/30 and had problems with registration, recall and language Is this depression or dementia?? MMSE is a screening tool not a diagnostic test for Delirium, dementia or head injury. It is a bedside test. It is affected by many factors like Education, ethnicity, speech, age, physical disabilities like hearing. Dementia is a Diagnosis of Exclusion. Depression is pseudo-dementia Normal: 25 to 30. Mild-moderate impairment: 18-24 Severe: less than 18 Depression is acute and past history. Patient is agitated and does not want to cooperate because they are aware that something is wrong with them. This patient gave up because she had insight. Recent and Remote affected They talk about their deficits Has treatment Repeat MMSE the following day? No, results will be the same. Improvement will be seen in 4 to six weeks Is it dementia? Is it delirium? not delirium and not dementia Is it depression? YEs, Depression is pseudodementia. Dementia (a diagnosis of exclusion; exclude causes by e.g. Neuropsychological testing is slow, insidious and progressive No past history Lack insight and confabulate. Loss starts from recent then remote. Hide the deficits No treatment

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Frontal Lobe Dementia Case: A 50-year-old man is in your GP clinic. His wife visited you already and told you that he changes the lane while driving without obvious reasons. He also has behavioral problems recently. He is in your clinic because his wife insisted him for a check up MMSE is already done and no need to repeat it. In MMSE, RECALL is 0/3, Language When patient is asked to hold paper and fold and put on his lap: 0/3 Task: a. b. c.

Take a further history Do at least 1 test to assess his cognitive function. Discuss your provisional diagnosis with the examiner and the reason for it.

(At the EXAM, Two papers outside: 1st is the STEM, 2nd one is MMSE results) History -

Counseling Do you have of any particular concern before I discuss to you the result? MMSE is a bedside cognitive function screening test. Its purpose is not to make a diagnosis but to indicate the presence of cognitive impairment due to delirium, dementia, or head injury. The advantage of this test is that it only takes 5 minutes which is therefore practical to use repeatedly and routinely. It can be helpful to monitor the progress or fluctuation in these disorders that may benefit from intervention. The disadvantage is that it can be affected by age, years of education, socio-economic status, the background of the patient/ethnicity and physical problems like hearing.

 As an example, better educated edu cated people ma y score well on the test despite having significant cognitive impairment. Discuss MMSE scores...normal 25 to 30. Does the result show that the patient has dementia? dementia? No dementia is a diagnosis of exclusion and requires complete assessment with further neuropsychological testing by the specialist before diagnosing it. In this case, the patient was admitted with depression which sometimes can be severe enough to cause pseudodementia. The score of 18/30 is most likely because of it. As you can see, the patients with depression gave up even before finishing the examination; however the patients with dementia will try hard to get a good score and complete the examination. Can we repeat the test tomorrow ? We can do it as it is brief and easily conducted test but it is better to wait until her mood symptoms get resolved. It can take three to 4 weeks for the drugs to work and then we can repeat the test and the score should improve with the improvement of her depressive symptoms. Can we adjust the score because she gave up on the latter part of the test ? No, we don't change the scores What we do if she gets low score when her mood symptoms are better ? We will investigate her with full dementia screening and further neuropsychological testing by a specialist. Can it be delirium? delirium? No the patient's orientation is normal and delirium has a rapid onset with a reduced consciousness and a fluctuating course over the 24hour period. Delirium has a cause. They can have hallucination but it is acute.

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How can I address you? (Why do you want to know my address?) Your wife is concerned about you. May I know why? (I have no problem) Did you notice any changes in behavior at home? (No.) Any changes in your mood? Irritability? Any problem with memory? Any problem with driving? Any problem in performing daily activities? Patient asks to repeat some questions. Have you had head injury? How is your mood? History of stroke, heart attack? Taking any medications? Smoking? alcohol? Drugs?

History: (summary) Having short term memory problems and forgetting many question. Patient had no insight. He was getting irritated and agitated. His understanding of simple language was impaired?

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EXAMINATION: DEMENTIA SCREENING TEST Clock face Drawing test (ask patient to draw a clock at ten past eleven)  patient is not able to do this FRONTAL LOBE COGNITIVE TEST Verbal Fluency Test How many items can you buy from the o supermarket and name them in one minute (Normal: >15; 15 or less is abnormal) Say as many words as possible in one o minute starting with letter F, A, S (normal is 15 words/letter or 30 words in all three) Or name as many vegetables. fruits, or o animals in one minute (10 or greater is normal) Interpretation of Proverbs  A stitch in time saves nine o Time and tide wait for none o Similarities and Differences: What's the difference between a bird and plane or table and chair Motor Sequencing: Fist edge palm or rapidly alternating movements

Mnemonic: DEMENTIAS - Things to rule out before Dementia can be diagnosed D - 3D's Dementia Depression Delirium Drugs (medications and illicit drugs) E - Emotions (Anxiety, loneliness, nervousness) M - Memory (Benign Forgetfulness) E - Endocrine (DM, Thyroid) Ears Eyes N - Nutritional (B12 Deficiency - Self-Neglect); Neurological problem (CVA, CVS) T- Tumors, Trauma (Head Injury) I - Infection (HIV, Syphilis) A - Alcohol, Amenesia (WKS) S - Chronic Schizophrenia Common causes of dementia: -  Alzheimer - 60 % of dementias dement ias Frontal Lobe - 10% Lewy Body Dementia - 10% -  Alcohol - 5% Vascular - 15% History -

Patients with frontal lobe dysfunction perform poorly and disorganized. Diagnosis and Management -

Based on the history and assessment, my diagnosis is frontal lobe dementia. This is because of the following reasons: History given by his wife (irritability and o personality changes) which shows personality and behavioral changes suggestive of frontal lobe dementia MMSE reveals problems with registration o and recall and cannot do a simple task which show problem in executive functioning My history shows that the patient had o problem with understanding and severe short-term memory loss (forgets questions and doesn't answer questions correctly), lack of insight and cognitive impairment Specific Frontal Lobe Tests are poorly done. o

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I would like to do investigations and look for reversible causes. Secondly, I will refer this patient to a psychiatrist for full medical assessment and neuropsychiatric testing. On MRI, Frontal lobe atrophy can be seen. There is no know curative treatment and supportive care is essential. This condition is managed by multidisciplinary care team including support groups. Median Survival time is seven years and often occurs between 40s and 50s. In Frontal lobe dementia, earliest manifestations are personality changes and alterations of behavior including social dysfunction.

Forgetfulness in a 56-year old man (Case 111) Case: A 56-year-old man comes in your GP clinic with complaint of forgetfulness but otherwise he is healthy. TASKS: a. Perform a history b. Do MMSE c. Explain to the patient the results and further management

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Can you tell me more about it? (My family is concerned that I am getting forgetful and that I am afraid I have dementia.) Do you forget about the recent things or the past events? Do you misplace items like car keys or keep the stove open? Any problem in performing daily activities? Do you find difficulty in planning and decision making? Do you find it difficult to remember the names of your friends and family? Did you notice any change in your personality? (like getting irritable or not being yourself Frontal lobe dementia) Any episode of confusion? (delirium) How is situation at home? Do you find it difficult to get along with family? Any problems or issues at work?  Any difficulty in finding you r way back home? home ? (tendency to wander) Any recent accidents? How much is this affecting your personal and social life? Do you have any headaches? Any previous head injury? episodes of falls? Problem with hearing? Vision? Chest pain? Shortness of breath? What about your diet? Any problems with waterworks? Bowel movements? How is your mood? Do you enjoy the things that you used to enjoy? Do you have any weather preference? Past history of Heart Attack? Stroke? Mental Illness? Infections like HIV or Syphilis? Are you on any medications? Family history of Mental illness or dementia and other serious conditions? SADMA? Is there anybody at home to take care of you?

Diagnosis and Management Dementia is only a diagnosis of exclusion and you need complete medical evaluation and further neuropsychological testing by a specialist. I will order the investigations and once the results are back, I will refer you to the specialist Give the reading materials. Once the results are back, refer the patient. Red flags. Be careful of driving and avoid any falls. Report any accidents at home. Investigations FBE, LFTs, UEC, BSL, URine MCS, TFTs, BGL Vit B12 and Folate, Vitamin D, Calcium and Phosphate, Syphilis and HIV (with patients consent) CT scan or preferably, MRI of the patient

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Dementia and Disclosure of patient’s condition (Book case 119  – pg.  – pg. 641) Case: Michael aged 70 years had come to see you in your GP clinic. He is concerned about his wife Jenny who had increasing forgetfulness over the past 6-12 months. She has misplaced her bag and bank cards on numerous occasions. She is spending very little time reading or knitting which were her favorite hobbies. You had seen Jenny last week with URTI. Michael is interested that if you can recommend Jenny for Nursing home placement and is requesting for your approval letter. Task a. b. -

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Focused history Management advice  Assess MMSE Draw clock test: Circle: 3 points o Number of the clock: 2 o Right numbers: 2 o Put the time of the clock: 2 o Investigations/Screening Test: RFTs, LFTs, TFTs, FBE, Blood glucose, o serum electrolytes, calcium and phosphage, urinalysis, serum vitamin B12 and folate, serum vitamin D, syphilis serology (HIV), CXR, CT/MRI, PET or SPECT scan for further information o Multidisciplinary assessment (aged care assessment team/memory clinic): geriatrician, occupational therapist, psychologist, etc…

Features Onset Course over 24 hours Insight Orientation Memory Loss Responses to mistakes Response to cognitive testing (question)

Dementia Insidious Worse in evening or night ( “sundown effect”) Nil Poor Recent > remote  Agitated Near-miss! Difficulty understanding

Pseudodementia Clear-cut, often acute Worse in morning

Present Reasonable Recent = remote Gives up easily easily “don’t know”; slow and reluctant but understands words (if cooperative)

DRUGS, SUBSTANCES OF ABUSE AND ALCOHOL  Alcoholic Couns eling Case: You are a GP and a 47-year-old businessman comes to you to discuss his alcohol consumption because he got pulled over by the police on his way to work. The blood alcohol level was 0.04. He was given a warning as it was near the legal limit and a sign that he had a lot of alcohol last night. He wants to discuss the safe level of alcohol and the effect of alcohol on a person. Case 2: Jarrod aged 30 years is a new patient to your clinic. Jarrod states that he has been drinking on average four SD per day per week for the last six months since starting his new job. Before this he was consuming on average 2SD drink two days per week. Last night while drunk, he met a minor accident and his girlfriend asked him to see you as she is not happy with his drinking habit. Jarrod works in a local supermarket and is otherwise fit and healthy. He is not on any regular medications and had no known allergies. Task a.

Further history

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Physical examination/investigation results (FBE 140, MCV 107, Plt 300, LFTs GGT increased, other enzymes normal including albumin, RFTs normal, BP 150/100mmHg, Management advice

History: Establish pattern of drinking: I know you are concerned about your drinking. It is a very good decision to come and see me. I need to ask several questions that may be personal. Is it alright? Since how many years have you been drinking (years)? How much do you drink per week? What type of alcohol do you drink (spirit, beer, wine)? Safe drinking: 1 SD for female, 2SD for o males per day everyday Where do you prefer to drink? With family, friends? Is it binge drinking or continuous? Are you aware of safe level of drinking? Have you noticed any ill effects of alcohol on you? Do you think you can drink heavily without appearing drunk (tolerance)? Are you able to work as efficiently? How is it affecting your relationships at work and in home? Have you ever had any accidents related to alcohol? CAGE: Have you ever thought of cutting down? o Do you feel annoyed when people criticize o you? Do you feel guilty for taking alcohol? o Do you take alcohol first thing in the o morning? How motivated are you on a scale of 1-10 to quit/cut down on your alcohol? Withdrawal Effects How long can you go without alcohol? Not o more than 1 day  How do you feel after a period of o abstinence? Do you think you need to drink to sleep? o Social effects Have you noticed any problems at work with o alcohol? How is your relationship with partner and o children? How is your financial situation? o Have you had any accidents/fights because o of drinking Health problems Have you ever noticed heartburn, gastritis, o heart disease, liver disease, anemia, hypertension, problem with memory, mood changes, depression, change in sexual performance (thought it was related to age) SADMA I will need to organize some investigations to see effect of alcohol. FBE, anemia (macrocytic-vitamin b12), LFTs, Lipid profile, serum lipase, BSL, liver USD, ECG, 1 SD = increase blood alcohol concentration by 0.01 Liver takes 1 hour to metabolize 1sd Counseling Feedback: History shows that you have been drinking more than normal. This is why I ordered some tests to determine the effect of alcohol in your body. The high level of alcohol may cause HTN, cause tummy problems (heartburn), increased weight, affects your liver, heart, brain, loss of memory, gout, sexual and social problem Listening: What do you think? -  Aim for safe level of drinki ng: Advise on safe le vel of drinking (1 30 ml spirit = 1SD; restaurant wine = 1.8SD)

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Goals (short-term) Strategy: Don’t drink daily o Drink only with food o Have a glass of water between drinks to o satisfy your thirst Switch to low alcohol drinks o Mix alcoholic drinks with non-alcoholic ones o  Always check bottle for SD o  Avoid high-risk situa tions (with alcohol ic o friends, going to the pub) If you are under pressure, tell them “my o doctor told me to cut down” When you’re stressed, take a walk; explore o new interests, plan new activities Start with a period of abstinence to test the o presence of withdrawal symptoms. If you want to drink, please report right away. We can manage your symptoms If you consider cutting down to safe levels or quitting alcohol, it will have a positive effect on your health, save money, have less family problems, and more time to spend with your family. I would also like to recommend for you to join alcohol anonymous which is a support group and recommend lifestyle modification for weight reduction and control hypertension, but it cannot be successfully done until alcohol is taken cared of. I’m always there with you to help you and support you, but in the end, the decision is yours. Offer to arrange for family meeting to discuss about alcoholism Review once the tests come back Refer to DETOX unit if dependent! Alcohol withdrawal scale: diazepam Red flags: Any other major concerns

Binge Drinking Case: One of your patients David who is a single parent brought his 10 years old son Simon to see you who got sprained ankle. You examined his son and diagnosed him as having a “sprained ankle”. On examination, apart from the sprained ankle, there Is no other injury, bruises, or scars. The child’s mother has left a few years ago and the child was looked after by his father. You have seen David 4 weeks ago in your clinic due to minor head injury after he got drunk and fell in the pub. At that time, you noticed he is a binge drinker of 24 pints on every weekend. You told him about his overdrinking, and you asked him to come back in 3 weeks’ time to discuss the issue, but he did not show up on his appointment day. Today, he is here for his son’s sake. David is a delivery driver. Task a.

Talk to the father about your concern

Strategies for Working with First Presentation of Alcohol Abuse FLAGS Approach Feedback: tell patient your impression about his intake level Listen to his reaction -  Advice about the bene fits of quitting Goals setting: keep it with safe limits or stop Strategies: quench thirst with non-alcoholic drinks before having an alcoholic one, avoid drinking on an empty stomach, switch to low-alcohol beer, think of a good explanation for cutting down on your drinking Strategies for Working with Persistent Problem Drinker Continue to encourage a reduction or cessation of alcohol intake

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Provide regular feedback regarding the impact of alcohol upon their physical, mental and social health Minimize the harms from polydrug use, by advising against and offering treatment for other drug problems Monitor prescribed and complementary medications to avoid predictable drug/alcohol interactions. Identify and respond to problems of poor medications adherence in heavy drinkers Use strategies to enhance patient engagement, including approaches to overcome barriers posed by cognitive disorders, language, and cultural issues or physical disabilities Define and attend to any specific medical and psychiatric conditions with relevant services that communicate regularly Consider strategies to minimize the consequences of specific medical complications such as CNS and peripheral nerve damage, liver disease, cerebellar damage, and/or peripheral neuropathy Engage psychosocial supports (“meals on wheels”, welfare, employment support, community and religious networks, financial or relationship counseling) to reduce personal and family harms Empower family and close friends to reduce availability of alcohol to encourage further engagement with clinicians able to help with alcohol problems Consider any medico-legal or ethical obligations, including driving assessment, child protection, welfare, guardianship and employment issues for use in certain trades or professions

Smoking Counseling Case: You are a GP and your next patient is a 30-year-old female. She has been recently discharged from the hospital due to recurrent attacks of bronchitis. She smokes 1 pack of cigarettes per day since the age of 18. A few weeks earlier, you saw her and advised her to stop talking. Now, she would like to quit. Task a.

Counsel her regarding smoking cessation

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You made a very good decision to come here to quit smoking.

 Assess the Motivation How motivated are you to stop smoking on a scale of 1-10? How confident are you that you will succeed (110)?  Assess Dependen cy How many cigarettes a day do you smoke? How soon after you wake up do you light your first cigarette (if within 30 minutes of waking up  high chances of giving NRT, bupoprion or champix)? Do you find it difficult not to smoke in a non-smoking area? Is it the first cigarette that is hard to give up? -

What is the pattern (smoke it with friends or out on a party or by self)? Do you smoke even when you are very ill? Have you tried to quit smoking before? If yes, why did you fail?

 Advice on Nicotine Withdrawal Within 24 hours of stopping or reducing nicotine, you may experience some symptoms such as depression, insomnia, restlessness, irritability, anxiety, difficulty in concentrating, drop in heart rate, increased appetite, craving for sweets and cigarettes, but these symptoms peak over a few days and will resolve after about a month.

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Benefits of quitting of Smoking Start to smell better Food tastes better Circulation of the blood improves Better immunity and less sick days at work Save money (2500 dollars/year for pack-a-day smoker) More time to spend with family Set positive example for children Minimize risk for heart disease, lung cancer, stroke, and gangrene Plan -

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Best way is COLD TURKEY. Decide the date to stop smoking within 2 weeks of making a decision.  Aim for TOTAL ABSTINENCE and not no t just cutting down. Review your previous attempts at quitting and what went wrong. Inform family, friends, and other smokers about your plan  Avoid alcohol and review coffee intake ( triggers) To decrease cravings, drink plenty of water, gradually increase other activities, avoid situations which could restart your smoking, and eat more citrus fruits (vitamin C helps reduce cravings). Nicotine replacement therapy Contraindications: pregnancy and CAD o Nicotine patches: 40% nicotine; no tar and o other carcinogens; Nicotine gums (2 or 4 mg): chewed o intermittently for up to 30 minutes 10x a day; poorly absorbed in acidic environment so decrease fruit juices when you’re chewing gum; can also cause mouth soreness and dyspepsia Transdermal patches (7 -21 mg used 16 0r o 24 hours):applied every morning on a rotational basis to non-hairy areas; can lead to skin rash Nicotine inhalers (4mg): single use only; 10 o or more per day for 6 months  All are equally effecti ve. Monotherapy is o preferred. Bupoprion (Zyban): atypical antidepressant with both noradrenergic and dopaminergic activity. It works on addiction pathways; 150 mg per day for 3 days then increase to BD x 9 weeks. SE: nausea, insomnia, dry mouth; CI: epilepsy, diabetes, pregnancy Varenicine (Champix): blocks the nicotine receptor and dopamine (addiction) pathway as well; does not contain nicotine and is not addictive; only available on prescription; CI: mental illness, kidney problems, pregnancy or breastfeeding; not yet studied on epilepsy; if you’re taking champix, not allowed to take NRT or Zyban. Start 1-2 weeks before quit date because champix needs time to build up in the body and to allow it to start working; can smoke while taking champix but make sure to quit by the date set; comes as a white (0.5mg) or blue tablet (1mg). Days 1-3 0.5mg OD o Days4-7:0.5mg BD o Week 2-4: 1mg BD (give prescription for 4 o weeks) 5-12 weeks: 1mg BD (give prescription for 8 o the rest of 8 weeks) If patient has stopped smoking, recommend o another 12 weeks of treatment for the longterm effect. Do not take double dose if you missed the tablet for >6 hours. Don’t share medications. If you start smoking again, may have nausea and vomiting.

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Reading material. If partner is smoker, ask patient to come and see you. Quit Line number. Review after 1 week and see progress. Support groups.

Request for a Repeat Prescription of benzodiazepine (Drug Dependence) Case: Michael aged 22 years comes into your practice with no appointment, seeking oxazepam to clam him down and sleep. He looks a little unkempt, is agitated, fidgets and shakes his legs while seated. The reception staff reports feeling uncomfortable around him and note that he was insistent to be seen today. There was no overt aggression. When you ask about history of benzodiazepine use, Michael becomes irritated and says he is asking for one script, but says he is been using them for years, started when he was having difficulty coming off speed and the he had then become dependent. He says his current supply was stolen with car this morning which has left him in anxious state with nothing to calm him down. He says he usually gets them from a GP on the other side of the town but unable to get there without car. He says he uses 5-6 tablets of 30mg oxazepam per day Task a. How will you address the request of the patient I am ready to help you. That is why I am here. Because you are not my regular patient, I need to ask a few more questions before I can help you. Why are you taking this medication? How long have you been using this medication? How many times do you take this in a day? Did you increase the doses by yourself? Drinking, smoking and illicit drug use? General health? serious illnesses, injuries or accidents (car accident)? Fits, falls, faints or loss of consciousness? Did you ever feel depressed or diagnosed with depression or other psychiatric illness. Management Explain: period of monitoring your use and moods or stress followed by graded reduction, along with regular appointments, support and resource materials or groups Diazepam (valium): long-acting  I will change the medication to the same medication but will work longer. Pick up daily supply. Morphine Request for Psychogenic Pain Case: You are working as night shift HMO in ED and your next patient is a young lady with abdominal pain. Investigations were done and were found to be normal. She is requesting morphine for her pain. This is not the first time she came with abdominal pain. Task a. b.

History (happening since 4 or 5 years; Management

History -

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I understand that you have this tummy pain and the investigations we did came out to be normal. This means that we could not find any organic cause for your pain. I also understand that this is not the first time. Since when is this happening? Confidentiality Do you think something happened in your life or a stressor that initiated it (happened after getting separated from partner)? How often does it happen? Do you think these episodes are related to any particular stress? Have you seen any doctor for this

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condition (saw GP and gave pethidine)? Where do you get the morphine from? Have you noticed any palpitation, agitation or sweating when you’re not taking morphine for your pain (if yes, means addicted)? Depression questions: How is your mood? Do you still find things pleasurable? Any changes in your sleep, appetite or weight? Do you think life is worth living? do you have any thoughts about hurting yourself or others? Whom do you live with? Any stress at home or at work? Any financial problems? Do you have enough support? Do you have friends? SADMA?

Management Let me reassure you that I will try to manage your pain. I understand that your pain is real. There is something called brain-body axis. Anytime our mind is stressed, our body starts reacting (e.g. diarrhea before exams). In the same way, your body is reacting by producing abdominal pain because of your stressors. Morphine is a short-term relief for the pain and has got many side effects. It can affect your respiratory system, heart, and is highly addictive. At this stage, I will give you panadeine forte to start with and refer you to the psychologist. He will do talk therapy (CBT) to relieve your stress and he will teach you how to overcome and handle your stress. If you need social support, I can organize a social worker. If you have financial issues, I can refer you to centerlink. There are a lot of support groups available for you. You are not alone. If dependent: Refer to psychiatrist for drug dependence management Do you agree with me or do you have any other questions? PSYCHOTIC DISORDERS Paranoid Schizophrenia Case: A 35-years-old female is in your GP clinic and wants a letter to the Department of Housing Authority because she wants to change her accommodation. She had schizophrenia for the last 10 years and she was on haloperidol. On examination, you can see some contact dermatitis on her hands. Task a.

b.

c. d. -

Psychosocial history (Neighbor wants to harm her and throws things into her home. She lives alone at Centre link and believes the TV is talking about her. Didn’t see the psychologist for 3 years and cut down dose by ½ since 1 year. Wash excessively with cleaning agents twice a day.) Mental Status Examination (well-dressed, (well-dressed, groomed, mood/speech normal, delusions of reference, auditory hallucination (hearing voices that neighbor is talking about her), delusion of persecution and husband is involved, dermatitis (throw things at home), no insight, good judgment, oriented, no suicidal ideation, stooped medication by herself she thinks she's feeling well) Give your findings to the examiner Diagnosis and differential diagnosis ENSURE Confidentiality! Psychosocial history: HEADSSS Psychological: o  Auditory/visual ha llucinations: do  you see or hear things that nobody else can see/hear? Delusions: do you think somebody  wants to harm you? Following you? Spying on you?

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(persecution) do you think you’re special? (grandeur) do you think someone is putting thoughts on your mind? (control) do you think you’ve done something wrong? (guilt) do you think radio and TV are talking about you? (idea of reference) Depression: how is your mood lately? Do o you enjoy the things you used to enjoy? Any problems with memory or concentration? Change in sleep, appetite or weight? Are you interested in your sexual life? Do you think life is worth living? Have you ever thought of harming or killing yourself? Or others? Have you ever tried this in the past? If you leave this room, what are you going to do?  Anxiety: Do you feel nervo us as a person o most of the time? Tremors? Palpitation/pounding of the heart? Social history Home situation: how are things going at o home? Are you experiencing any problems? Employment: do you work? Any problem at o work? Any financial problems? Social circle/friends? o Hobbies? What do you do for relaxation? o Past history: mental disorder? Depression? Psychoses? Medical illness? Thyroid problem? Medications and side-effects? Family history: mental disorder? Thyroid? SADMA!!!

Mental Status Examination -  Appearance: prope rly dressed? Unkempt? Unke mpt? Disheveled? Behavior: cooperative/uncooperative; comfortable? anxious? Restless? Irritable? Speech: coherent, fluent, understandable? High/low volume? Monotonous/changing tones? Pressured speech? Mood/affect (congruent) Perception: hallucinations hallucination s Psychosocial history Thought: Content: delusion/suicide o Form: how contents of thought are o expressed (ie flight of ideas, loose associations,tangentiality) Cognition (Orientation): Time? Date? Person? Insight: do you think that you need help? Or medical advice? Judgment: what would you do if there is a fire in this building?

Differential diagnosis: a. Organic causes (brain tumors) b. Drug-induced or substance abuse c.  Anxiety disorder d. OCD highly unlikely Management: I will need to refer her to the hospital because she is living alone, has ideas of reference, paranoid delusions and is lacking insight. I will need to contact the specialist at the hospital to review her. This will be for her safety. Urgent referral to psychiatrist for possible admission: due to loss of insight, paranoid ideation, not taking medication, living by herself; If patient refuses: involuntary admission

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Relapse of schizophrenia (Tardive Dsykinesia) Case: A 40 year old lady with schizophrenia for the last 15 years comes to your GP clinic because she has movements of her face. Task a. b. c. History -

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Psychosocial history Diagnosis Management

Ensure confidentiality Tardive dyskinesia-- more with typical antipsychotics Can you stick out your tongue for me? Side effects: postural hypotension (giddiness, light headedness with posture change),dry mouth? Bov? Urinary retention? Constipation? Milky discharge on breasts? Loss of libido? Decreased sexual drive? Problem with periods EPSE: stiffness? Restlessness? Gait problems? Bradykinesia? Cogwheel rigidity? Tremors? previous history of NMS? Fever, stiffness, confusion Medication: are you taking the drug? Did you change your dose? When did you see your psychiatrist? Do psychosocial history? Do you think you need medical help?

Management Refer back to psychiatrist. Stop drug and change to other medications. Risk of breakthrough psychosis May consider admission Drug-Induced Psychosis Case: An 18-year-old male who failed in one of his exams came to your GP clinic for consultation. He felt depressed since then and suffered insomnia. He came requesting for sleeping pills. On assessment, you detected that he is suffering from delusions, hallucinations, and other symptoms upon which you settled with the diagnosis of acute psychosis. He also admitted the use of illicit drugs. His parent came to the clinic to discuss his case. The patient gave permission to discuss his case but not to disclose his illicit drug use.

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Ice-Induced Psychosis Case: A 20-year-old man was brought to ED by his friends where you’re working as HMO. He had hallucinations and delusions. He was aggressive and violent. You sedated him with medications. He went to a party last night and you suspected he used ICE. His father is here to see you. He knows about his son’s ICE usage. Task a. Relevant history b.  Advise further manage ment c.  Answer his question s History -

Task a. Talk to the father b. Explain current situation c.  Answer his question Questions: Is my son using drugs? Is this condition due to depression? Can I take him home? His auntie had schizophrenia, does he have this also? Can he develop it? Counseling Let me assure you that your son at the moment is having a thorough assessment as we found him suffering from a sort of psychiatric emergency that we call acute psychosis. I have contacted a team called CAT who’s undertaking the assessment. This team is the crisis assessment team. Psychosis is not a specific disorder. This is a condition where a patient has severe impaired sense of reality with emotional and cognitive disabilities. The patient talks and acts in a bizarre fashion and may suffer from hallucinations wherein he can see or listen to voices or things which are not real or cannot be experienced by others around. Also, he can suffer from delusions which are

ideas that are contrary to fact. There are many causes for this condition. Schizophrenia which needs around 6 months to be diagnosed or schizophreniform or delusional disorder. Some patients may have medical conditions which we call organic-induced psychosis. Others may use illicit drugs which can experience it as sequelae. We call this drug-induced psychosis. If any patient is diagnosed with acute psychosis, it is an emergency situation as the patient is not safe for himself or for people surrounding him. They may have suicidal ideation or any psychotic ideation which could make them very aggressive and harmful to themselves or others. Under the mental act, we usually admit involuntarily all acutely psychotic patients until we stabilize their condition and we do further assessment to find out the cause. Usually, many persons share the management of those patients for short-term and long-term management. Family will be notified and a meeting will be done to discuss the management. We need lots of support from you. The psychologist, psychiatrist, mental health nurse, social workers can be part of this team as well as myself as your GP. You can go to the hospital with your son and you will be notified with the further steps. Do you think my son is using illicit drugs? drugs? As I have mentioned before, there are many causes. We need to assess him first. Our first priority is to stabilize your son, then find out the cause and you will be informed accordingly.

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I understand you are here to talk about your son. Let me assure you that he is in safe hands. Before I explain the further management to you can you share what you know about his condition? OR Do you know what happened in the party? OR It can be quite common at a young age and I understand that John has a problem related to this. may I know a bit more about it? Since when is he using it? any previous hospitalization like this because of this? Any intervention done or step taken regarding this issue? Are you a happy family? How is your family life? Any particular issue? Does he have any siblings? How is his relationship with them? Anybody else in the family using drugs? How much is this affecting the family? Does he go to school or uni? How is his performance over there?  Any problems at uni or work? wo rk? Any problems problem s with the law? Any of his friends having similar problems? Any other hobbies or sports? How is his mood most of the time during the day? Does he enjoy the things he used to enjoy? What about his sleep? Did you notice any changes in his weight or appetite? Did he have any previous attempts to harm himself or somebody else? Did he ever talk about seeing/hearing things/voices that nobody does? Has he exhibited any strange behavior?

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 Any previous medica l problems such as thyr oid disease? Does he take any medications? Any allergies? FHx of similar problems and psychiatric illnesses? Smoking? Alcohol?

Management Most likely the condition that he is having is called iceinduced psychosis. Psychosis is loss of contact with reality that usually includes hearing/seeing things that are not there and having abnormal beliefs. These are called hallucinations and delusions. In simple words, it is the changed and different way of thinking, speaking and behaving that can make a person aggressive and violent and unaware of his surroundings. This is what John is going through at the moment and this is because of his ice usage. It can change the chemicals in the brain to produce these effects. Now he is safe and stable. He will be assessed by the CAT for psychiatric assessment. He will be admitted in the hospital under care and supervision because in this condition he can harm himself and others. Even if the patient refuses, they can be admitted involuntarily and it is in the best interest of their safety. They can give him antipsychotic medications for short-term to treat his intoxication. He will also undergo some investigations such as FBE, U&E, LFTs, RFTs, BSL, TFTs including urine and blood drug screen, alcohol concentration and CT scan to r/o any organic cause. Once discharged, he will be followed up by psychiatrist and GP. He can also be referred to a drug rehabilitation center to help him stop drug usage and develop new coping skills that make the relapse less likely. -  Arrange family meeting . Support groups. Refer to psychologist if father is depressed. Is there any antidote available? available? No. Is ice addictive? addictive? It is a highly purified form of amphetamine and that’s why it is powerfully addictive. Will this lead to schizophrenia? schizophrenia? Using this drug is a risk factor for mental disorders. Will you report to authorities if drug test is positive? positive? It is a confidential issue. Once he is stable, we will talk to him and discuss further plan of action with him. Postpartum Psychosis

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Management From the discussion we have, your wife might be suffering from a condition called postpartum psychosis. It is not an uncommon condition but it needs to be treated urgently. I am concerned about you and your baby’s safety. I safety. I will need to admit your wife and I will call the psychiatric registrar to come and take a look. She will also be seen by the consultant.  At this stage, they might start with ECT and antipsychotic medications. How is your mood? Are you alright? I can organize a social worker for you. Centerlink for financial problems. I don’t think she will agree to be admitted . I am sorry but she will be admitted involuntarily under the mental health act and I will call on the crisis assessment team. Don’t worry. We will be here to take care of her. Prognosis Prognosis is good. If you need any help or you have any other concerns, please don’t hesitate to contact us. MOOD DISORDERS Loneliness or “Empty Nest Syndrome”  Case: A middle-aged lady presented in your general practice. She complains of feeling down and depressed for a few months. You asked her to come for consultation a few weeks back but did not come. Task a.

Case: You are an HMO and your next patient in ED is the husband of a 25-year-old lady who had her first baby 2 weeks ago. He is concerned about his his wife’s behavior but the patient is not concerned about her problem. The husband has got the consent to talk about his wife. Delivery was NSVD. She did not want to come and see the doctor, so the husband came to talk to you while waiting at the waiting room with the baby and the nurse. Task a.

b.

History (doesn’t take care of the baby and husband too tired to take care; scared to leave baby with her; behavior is odd; doesn’t sleep much; lost weight, feels like they’re both devils) Management (immediate and long-term management)

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History (poor appetite, lack of sleep, early morning awakening, do not socialize, appetite okay but does not find it pleasurable, no friends, don’t feel like talking to friends, stay-at-home, separated with husband but not talking) Provisional diagnosis Management

Differential diagnosis Loneliness Depression  Adjustment disorder  Anxiety Bipolar disorder (depressive episode) Organic (menopause, hypothyroidism) History

History -

not worth living? Does she feel guilty about anything?  Any time that her mood is rea lly high? Psychotic: does she hear/see things that others do not? Does she have any strange feelings or experiences? Does she tell you that somebody is putting ideas on her head or that the TV or radio is talking about her? Does she have strange experiences or abnormal thoughts? Does she think there might be something wrong with her? How is her general health? Has she been diagnosed with any mental illness before? Family? SADMA? I can see that you are tired. Do you have enough support? Whom do you live with? Are there any financial problems at home?

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Confidentiality Could you tell me what you meant by change in behavior in your wife? Is she breastfeeding at all? Is she taking care of the child? Mood: How would you define her mood? How about her sleep? Appetite? Weight? Do you think she’s weak and has no energy? Does she think that life is

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Confidentiality How is your mood? Do you have low mood most of the day? Do you still find the things you do pleasurable? How is your sleep? Appetite? Weight? How is your energy level? Do you think life is worth living? Have you ever thought of harming yourself Who are you living with? Do you talk to each other? How about your kids? Family?

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 Are you sexually active? Stable partner? Wha t do you do? Do you hear or see things which others do not? Do you have strange experiences? How is your general health? Do you have weather preferences? Do you have swelling all over the body? Weight gain? Lump in the neck? Menopausal symptoms: irritability? Dryness of vagina? Hot flushes? Mood swings? Pap smear? Mammography? SADMA?

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Diagnosis -

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From the discussion we have, you most likely have a condition called loneliness or empty nest syndrome as you have no one to talk talk to at home, your husband is estranged to you and your children have grown up and moved out. These are all contributing to it. There are a lot of things we can do about it. You can join the community clubs, or do voluntary work. Meet and make new friends and create a social circle. You can explore your interests and activities. I can arrange a social worker if you need a help. I will refer you to a counselor with whom you can share and talk about things. If you agree, I am happy to organize a family meeting and tell them about your condition. You can always give them a ring or talk to them via skype to see them. Lifestyle modification. Review. Referral to psychologist. Reading material (Beyond Blue).

Normal Grief Case: You are a GP and 18 years old university student comes to you with complaint of poor sleep since her father died. She can’t concentrate on her study and she is anxious as the exam is approaching. She visited you 2 months ago with some flu. She was alright at that time. Tasks -

Focused history Management

Stages of Grief: (normal grief can go up to 3 months) Shock and disbelief Grief, anger, despair, self-blame, guilt -  Adaptation and accep tance of the loss If the timing and severity increase, there is high risk of suicide and psychosis. History -

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Sorry to hear what has happened. How are you coping with this situation and your family? Is there anything you want to share with me regarding your dad? Confidentiality!

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Sleep problem? How is the problem? Hard to initiate or wake up early? Night sweat? Do you feel fresh in the morning? Any nap during the day How is your mood? Appetite? Daily enjoyment as usual? Do you feel active or lethargic? Suicidal ideation? Harming yourself or others? Do you think life is worth living? Do you ever feel or hear things that other people cannot? Do you feel someone is spying on you? Whom do you live with at home? How is your relationship with your family? Since your father’s death, have you talked to someone else about your feeling SADMA? Tea and coffee drinking habit during in the evening? General health? Past history of thyroid problem or any mental illness? Any family history of similar problems?  Any family history of mental il lness? Insight and reliability

Management The most likely diagnosis at this stage is one of the normal emotional reactions to people who lost someone who is very close and emotionally bound. It is normal to feel disbelief, anger, sadness. However, I can help you with some advice in many ways. Socialize more – more – talk  talk to friends and family o  Approach religiou s resources – resources – according  according to o your beliefs to help your relax spiritually I can also organize a support group for you o and your family Sleep problems – problems – provide  provide with written o materials regarding sleep hygiene and other techniques   Avoid having tea or co ffee in the evening   Avoid having hea vy meal before sleep   A glass of warm milk be fore sleep Try to maintain the room  environment being not too hot and not too cool Try to sleep in dark and quiet  room Have a routine to go to bed at the  same time everyday   Avoid day time naps Meditation before bedtime can  help you relax I can arrange a referral letter to  psychotherapist who will teach you relaxation technique. I can also organize social workers to visit you at your place as required. It will be difficult for you to go to exam right now, so a letter will be provided to your principal of your school to reschedule your exam University counselor is also available for counseling of such cases Sleep hygiene and life style modification o Prescription – Prescription – short  short acting benzodiazepine o If you feel very low at any time and you feel o stressed and frustrated with yourself, please come to me and contact crisis control center. Please do not stay alone and I will review o you in 3 days’ time about your progress

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 Anniversary Grief React ion

SSRIs for some time. She did not show up for previous followups for the last 2 months. She is here today because the receptionist has called her.

Case: Your next patient in GP practice is a middle aged woman who came for regular checkup regarding her BP. She had no emotional problems before but during the last weeks, she was tearful and often crying. Her husband died of heart attack 12 months ago.

Task

Task

Criteria: a.

b.

History (started 2 weeks ago, when I was cleaning the closet and putting his clothes aside, and started to smell his scent; I can feel his presence) Diagnosis and Management

a. b.

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History -

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I understand that you came to see me for review of your blood pressure. Is everything alright? Have you been checking your blood pressure? I also understand that you have been tearful and crying. How do you feel right now? (Patient starts crying – crying – Offer  Offer tissue and Water). I know it is a very hard time for you. I am here to help you. If you feel like talking to me, let me reassure you that everything we talk about it confidential. I will not breach this confidentiality. When did it start exactly? How did you cope after your husband’s death? How’s your mood? Do you still find things pleasurable? How’s your sleep? Appetite? Appetite? Weight? Psychomotor retardation or agitation? Do you think life is worth living? Do you feel guilty about your husband’s death? Have you thought of harming yourself or anybody else? Do you hear or see things that others do not? Do you have any strange experiences? Whom do you live with? Have you got enough support from friends and family? Do you go out with friends?  Are you working at the moment? mom ent? Can you do yo ur day-to-day activities? SADMA?

Diagnosis and Management From the history, most likely what you are experiencing is anniversary grief reaction. This is normal, expected and understandable especially when a close person/loved one passed away. Your mind ventilates the feeling through crying. To feel your husband’s presence is a part of anniversar y reaction and it doesn’t mean that you are getting insane. I understand that you are going through a tough time. What you are feeling is like a bruise. It will heal without scarring. You will feel better once the anniversary phase is better. But what you need at this time is emotional support. We will manage your condition with a multi-disciplinary approach (Psychiatrist, Psychologist, Occupational Therapist, Social Worker, Counselors, and Mental Health Nurses). I will refer you to the psychologist whom you can share your problems with and to help you cope with the grief, social worker, and grief support group. If you are happy, I can arrange a family meeting. Can’t you just give me medications doctor ? You do not need any medications at this moment. All you need is a lot of support during this hard time. I will need to see you in a week’s time to see your progress. Referral. Review. Major Depression with Psychotic Features Case: You are a GP and a 42-year-old nurse comes to see you. She had been accused of an incident at the hospital around 5 months ago where a patient had died. The nurse has been cleared by the coroner and the case was adjourned. The patient did not feel well after the incident and she was treated with

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Perform Mental state examination Tell examiner diagnosis and management plan

 Anhedonia, depre ssed mood, suicida l ideation, sleep problems (early awakenings), lack of energy, problems with concentration and decision making, lack of sexual desire and appetite Diagnosis depends upon the presence of 2 of the above along with suicidal ideation, persisting for at least 2 weeks or any 4 of the above without suicidal ideation. Risks/criteria for admission: not eating/drinking appropriately, suicidal ideation, lack of support at home, not taking/responding to antidepressants

Counseling Show empathy. Confidentiality statement. From the notes I understand that you have been upset since the incident five months ago. Can you please tell me exactly what happened? I understand it is very difficult for you to go through that experience one more time, but it will really help me to understand the situation. When exactly did you start feeling bad about yourself? How was your mood before the incident? Were you eating and drinking well? Were you able to work? Have you ever been diagnosed with depression or other illnesses like thyroid problems, diabetes, infections? What happened after the incident? Did you notice any changes in your weight or appetite? Were you feeling guilty all the time? Any change in your sleep pattern? Any early morning awakenings? Did you feel like harming yourself or others? Do you think your life is worth living? Have you thought about how you are going to do it? Any plans? Did you buy something for that plan? Please tell me, whom do you live with him at home? Any partner? Kids? Relatives? Friends? Neighbors to take care of you? Are you working at the moment? When did you leave? Can you tell me more about the medications that were given to you? How long did you take them? Did they help to improve your mood? Why did you stop? Do you see/hear things that others don’t? Do you have strange experiences? Do you think some people are trying to harm or spy on you? Are there repetitive thoughts that you can’t get rid of? Do you think the TV or radio talk to you? Can you please tell me your date of birth? Day? What would you do if there is fire in the room or envelope on the street that has an address on it? Do you think you need medical help? May I ask why you’re here? What are your plans for the future? Are you planning on anything? MSE (ASEPTIC) Appearance (dress, posture, hygiene) Speech (rate, tone, volume) Emotion (affect and mood) Perception (hallucination, illusion, derealization) Thought (delusions, suicidal/homicidal ideations, obsessions, logical/coherent) Insight and Judgment Cognition (orientation to time, place, and person; memory; LOC)

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I would like to address my MS findings to the examiner. The patient looks appropriately dressed for the weather. She looks gloomy, tearful, and avoiding eye contact. She is sitting with a drooping posture. The affect appears constricted, although the mood is depressed and irritable at times. The patient speaks with a monotonous voice, sometimes with long pauses in between where she avoids answering. I also found that the patient has delusions of guilt. She feels helpless and has suicidal ideations although no particular plan is present at the moment. Her cognition is distracted where the patient is not able to concentrate adequately although her memory is intact. Her insight and judgment is impaired. Based on the examination findings my most likely diagnosis is major depression with psychotic features. It is obvious that the patient is neglecting herself. She needs to be evaluated appropriately by the psychiatric team so I will need to refer her to the hospital if required under the mental health act. The most likely management is anti-depressants with or without ECT followed by CBT later on.

Postpartum/Postnatal Blues Case: Your next patient in GP practice is a 25-year-old Jane who is 7 days postpartum. She feels exhausted, and has lack of energy, and gets quite irritable at times. She is wondering if she is lacking some vitamins and seeks your advice.

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Postnatal depression with psychosis/melancholic features Case: 30-year-old woman came to your GP clinic. She has 2 children 30 months and 2 months. She presented with 2 weeks history of tiredness, weight loss, and inability to sleep. She’s always worried about her baby as she thinks baby will die from SIDS. You arranged some investigations for her 1 week ago and all the tests are normal. Today, she’s here to collect the report. Task: a. b. c. History -

Task a.

b. c.

History (1st baby, feels very tired; planned pregnancy; takes care of the baby; complicated labor – labor – prolonged  prolonged for 14 hours, eclampsia; cannot sleep at night because baby is crying all the time; husband needs to travel a lot; needs help; “I love my baby”; no past history of depression) Diagnosis Management

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Risk factors Prolonged or difficult labor First baby History -

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Congratulations! How was the pregnancy? How was the labor? Is it your first baby? Is everything okay now? How is the baby? Did you start breastfeeding?  Any problems with that? I understand understand that you have tiredness and you’re irritable? Confidentiality  Any SOB or did you have a lot of blood loss? Do yo u think you’re pale? Any weather preferences? How are your waterworks? How’s your discharge? Any offensive smell? How’s your diet? Mood: How is your mood? Do you still find things pleasurable? How’s your weight? Appetite? Sleep? Have you ever thought of harming yourself or the baby? Do you think life is worth living? Do you hear/see things that others do not? Do you have any strange experience? SADMA? How are things at home? Do you have enough support from friends, family and husband? How is your relationship with husband? Any financial problems?

Diagnosis and Management Most likely you have a condition called postpartum blues. It is more common during the first pregnancy and basically, it happens because of hormonal imbalance. There are also contributory social factors. In your case, it is the lack of social support.

You’re doing a good job as a mother. Don’t worry. I do understand that it is difficult to be a mother for a first time and you need support. I will organize a social worker to help you. If you like, I can organize a family meeting and talk to your husband about the issue. I would also like to refer you to a counselor to teach you how to cope with stress. I would organize basic investigations especially FBE, ESR/CRP, urine MCS, BSL, and TFTs. Do not worry. You are not alone. These blues or mood swings should be fine in around 1-2 weeks (1 month maximum).

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History Diagnosis Management

I understand from your notes that you are here because you have trouble sleeping, has lost weight and are always tired? Can you tell me more about it? Can you describe me your sleep pattern? I know you are tired (anemia, chronic illnesses, psychological), but do you have any SOB, palpitations, fever? How is your mood? Sleep? Weight? Appetite? Have you lost interest in the activity which used to be pleasurable before? Do you think life is worth living? Have you thought of harming yourself or anybody else? Have you ever thought of harming your baby? Psychosis: do you see, hear, feel things which others do not? Do you have any strange experiences? Do you think someone is putting thoughts into your head? Or think something/someone is after your thoughts? Do you think tv/radio/newspaper is talking about you? Do you think you’re a good mother? Insight Judgment Cognition HEADSSS PMHx/FHx/SADMA

Risk factors for postpartum depression Previous history of postnatal depression Previous history of any mental illness Unplanned pregnancy Difficult marriage/lack of support Social isolation Complication during pregnancy -  Abused childhood Management You have a condition called postpartum depression with some psychotic features. Our body and mind are interconnected. When our mind is too stressed our body starts showing symptoms and that’s the reason why you’re having tiredness, weight loss and sleep changes. We did some investigations and all the tests are normal which means that there is no organic cause for your symptoms. I have to admit you to the hospital. I will call the ambulance. In the hospital you will be reviewed by a

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psychiatrist. They will start you with lithium, antipsychotic medications, and antidepressant medications as well. If you don’t get better with this management, the specialist might also consider doing ECT. I would also like to speak to your partner and other family members because you need a lot of support. In the hospitals, we have mother and child unit so you can stay with your children. I would organize a social worker to help you. Most likely, the breastfeeding will be terminated (bromocriptine – (bromocriptine – dopamine  dopamine agonist). Later on, you will also be seen by a psychologist and they will consider doing CBT.  According to the mental health he alth act, I need to go for involuntary admission. I am sorry. Prognosis is good once treatment is administered but there is a chance of relapse in the future. Consider lithium prophylaxis in future pregnancies. OFFER BABY CHECK!

Mania Case: You are GP and a 35-year-old David comes to your clinic as his wife has some concerns about his behaviors. Case 2: Your next patient is 24-year-old university student brought by parents who are concerned because of his change in behavior for 2 weeks. He seems to have been hyperactive, sleeps less and has slept with 3 girls in the last 2 days. He has been drinking a lot of alcohol and are worried he might get into an accident. Task a. b.

History (6 minutes) Explain to examiner differential diagnosis

Differential Diagnosis Bipolar Mood Disorder Schizoaffective Disorder Personality disorder Hyperthymic personality (no treatment unless they come with mania or depression)  Alcohol/drug depe ndence  Anxiety disorder Hyperthyroidism Treatment  Admit Lithium carbonate, sodium valproate  Anti-psychotic  Anti-depressant (nee d to used with caution with mood stabilizer) Psychiatrist review and long-term followup Mental health care plan -

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Thought:

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Stream: amount and speed of thinking Form: how patient puts his thoughts across; o loose association/derailment, tangentiality, flight of ideas, circumstantiality (overinclusiveness or beating around the bush) content: delusion, thought broadcasting/insertion/ideas of reference/suicidal ideation perception: hallucination and illusions Cognition/Insight and Judgment o

Examination Findings My patient's general appearance is okay. She is casually dressed and well-groomed. Her behavior is restless and agitated. Volume of speech is low and language is good. She describes her mood as "okay". Her affect is congruent with the mood. Her thought streaming is okay. She exhibits flight of ideas and has delusions of grandeur. She believes that the president is going to die and she needs to save him. Perception is alright. She does not have hallucinations or delusions. She is oriented to time, place and person and has impaired insight. Differential Diagnosis Mania Drug-induced -  Acute psychosis Hypomania Diagnosis and management Urine drug screen -  Admit patient Call psychiatric registrar: they might start him on mood stabilizers ANXIETY DISORDERS Generalized anxiety disorder (JM 1259/1260) Case: -

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Mania MMSE Case: Your next patient is a young uni student brought in by their concerned parents. She is insisting to fly to US to meet the president. Task a. b.

Mental state examination Present findings to examiner

MSE -

Confidentiality General appearance and behavior: restless and agitated Speech and language: rate, volume, quantity; fluency, range of vocabulary Mood and affect: congruent/incongruent; appropriate/inappropriate (related to situation)

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R/O drug dependence/withdrawal, hyperthyroidism, cardiac arrhythmias, pheochromocytoma, depression, Diabetes

Do ECG, BSL and Urine at the office during his first visit DSM criteria: “UNREALISTIC” worries o Uncontrollable worries o Symptoms are not the direct result of any o organic or psychiatric disturbances 3 or more symptoms: o Irritability  Restless, keyed up or “on edge”  Easily fatigued  Difficulty concentrating or “mind  going blank” Muscle tension  Sleep disturbance  Management: Relaxation techniques: YOGA AND o MEDITATION Lifestyle modification: Diet o Physical activity: 30 minutes brisk walking o most days of the week Refer to psychologist for CBT o Sleep problems: sleep hygiene; may give o short-term benzodiazepines (up to 2 weeks but usually 2 days to prevent drug dependence)

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SSRIs after 3 months of lifestyle modification and CBT

Panic disorder with Agoraphobia Case (Panic disorder): A 30-year-old female came in to your GP attack saying she had a heart attack 4 months ago when she was visiting a postnatal class. All PE and investigations at that time were normal. Patient does not understand her condition, hence came to you for explanation. Task

a.

b. c. d.

Focused history (can’t breath, heart beating fast, fainted; anxious, stressed, other investigations normal; given sleeping pills but did not take it; no longer going out because she is scared of recurrence; worry about a lot of things says husband but she does not believe) No further examination Diagnosis Management

Case 2 (Panic attack): Sheila aged 35 years presents to your GP clinic with history of sudden onset of palpitations, trembling, sweating and chest tightness. She also had numbness and tingling feeling in her arms, legs, and around the lips. She had similar episodes in the last few months and was investigated in the hospital with negative results. Task a.

b.

c.

Focused history (2nd attack, was sitting in the staff room and started feeling palpitations, trembling, sweating and chest tightness; lasted about 30 minutes, blood tests; ECG normal; coffee 5-6 cups, father with HPN and angina; works as assistant teacher; feels stressed but able to manage it; relationship with partner is okay; no financial constraints; mood is okay; sleep and appetite is good; life is still worth living; smokes 5-10 cigarettes/day; drinks 2-3 SD/day) Physical examination (looks anxious but well; PR 74, BP 110/70, thyroid normal; chest and heart normal; abdomen normal) Differential diagnosis and management

Features (DSM IV) Panic Attack Criteria Discrete period of intense fear or discomfort o in which four or more symptoms develop abruptly and reach a peak within 10 minutes SOB or smothering sensations  Dizziness, unsteady feelings, light  headedness or faintness Palpitations or accelerated heart  rate Trembling or shaking  Sweating  Feeling of choking  Nausea or abdominal distress  Depersonalization or derealization  Numbness or tingling sensations  Flushes or chills  Chest pain or discomfort  Fear of dying  Fear of going crazy or of doing  something uncontrolled Organic disorders that stimulate a panic o attack are hyperthyroidism, pheochromocytoma and hypoglycemia Management: o Reassurance and explanation  Support 

Breathing techniques to help control panic attacks and hyperventilation Breathe in and out of paper bag    Acute attack: benzodi azepine Lifestyle modification  CBT: teach patients to  identify,evaluate and control and modify their negative fearful thoughts and behavior SSRIs  PANIC Disorder: Presence of both: Believes having heart attack o Recurrent panic attack in which the onset is o not associated with a situational trigger  At least 1 of the panic attacks h as been o followed by one month of one or more of the following Persistent concern about having  additional attacks Worry about implications of the  attack or its consequences Significant change in behavior  related to attacks Presence or absence of agoraphobia o Panic attack are not due to the direct o physiological effects of a substance, medication, general medical condition or another mental disorders

Differential Diagnosis Panic attack -  Anxiety disorder Conversion disorder  Agoraphobia: extre me anxiety about abou t being in a place whe re escape might be difficult or embarrassing. Extreme cases lead to a situation where the person rarely leaves home History -

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Physical -

Confidentiality Please tell me more about what happened 4 months ago? Where were you at the time? Can you describe the environment? How many people were in that room? Was it a crowded place? Where was the baby at that time? What symptoms exactly did you feel? Was that the first episode? What happened afterwards? Did you lose consciousness? I understand from the notes that you had a lot of tests done and the results were all normal. During the last 4 mos, have you had similar symptoms (e.g. palpitation, chest tightness, DOB, dizziness)? Where? What situations? Environment? Can you describe yourself in terms of your personality?  Are you worried abou t having a similar ep isode again? Did you attend more classes afterwards? Do you think you are evading public spaces/closed spaces since then? How is your mood/appetite/sleep? Are you able to perform daily household activities? Have you thought about harming yourself or others? How’s the baby doing at the moment? Are you coping well? Are you breastfeeding? Do you have enough support at home? PMHx: thyroid, heart, mental illness; SADMA Examination General appearance Vital signs Thyroid examination Chest and heart  Abdomen

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Management Most likely you have a condition called panic disorder with agoraphobia. It is a feeling of excessive anxiety that causes symptoms like palpitations, sweating, etc. Usually, there is no cause for this problem. I will refer you to a psychologist. We will try and help you to overcome this problem as it makes it difficult for you to go out in public. We will teach you to how to avoid these attacks and what to do if you have one. This treatment is called CBT. We will also teach you some breathing techniques that will help whenever you are stressed and anxious. If your symptoms are not relieved by CBT, the specialist might start you with SSRIs. Also, if you develop recurrent attacks with increased severity, SSRIs are required. I can ask a social worker to come and visit you at home. Reading materials; Review materials and followup with psychologist Obsessive Compulsive Disorder (OCD)

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Obsessive Compulsive Disorder Case: A university student came to see you at a GP clinic. He failed his exam recently. Task a. b. c. History -

Case: a 30-year-old nurse came in to your GP clinic. She was seen by your colleague a week ago. She has repetitive, frequently intrusive thoughts of washing her hands very repeatedly because she thinks her hands might be contaminated and transmits infection to patient. Investigations were done and she was diagnosed with OCD. She’s feeling anxious and frustrated and now thinks whether she can take some time off from work.  A university student studen t comes and when someone tells “king”, he starts to walk. Task a. b. History -

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History (patient wearing gloves) Management plan

Confidentiality! Can you talk a bit more about it? Do you think it is rational to keep washing hands? How is it affecting your life? Do you have any other repetitive thoughts? Since when? Are you a perfectionist? Mood: I know this is a frustrating time for you but how is your mood these days? Sleep? Appetite? Weight?  Anhedonia? Have you ever thought of harming anybody or yourself? Are there any times when your mood is really high? Do you see/hear/feel things which others don’t? any strange experiences which others find hard to believe? Insight: do you think you need help? Judgment: fire or envelope question Social history: how is the situation at work (stressed)? Home? Whom do you stay with? Financial issues? Happy family? SADMA

Management You have a problem called OCD. Do you know what it is? OCD is one of the anxiety disorders. It is a common condition. People experience recurrent and persistent thoughts (obsession) leading to anxiety and compulsion. I would like to refer you to a psychiatrist and psychologist. They will do Behaviour Modification Therapy (Exposure and Response Prevention) which means the therapist will expose you to the obsession and will teach you how to overcome your anxiety.

The psychiatrist may also consider giving SSRIs to relieve your anxiety and maybe some short-term benzodiazepines to help you with your sleep. Do not worry. The prognosis is good.  Am I crazy ? No. this is an anxiety disorder. Most likely because you are too stressed at work. Take things lightly and do not bottle up things. If you want to take time off, it is a very good decision. Relaxation and Meditation Review and reading materials

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Take a history Diagnosis Management

I understand that you have come here because you worried about failing your exams. I am sorry about this. Why do you think it happened (I have trouble studying because of my thoughts)? Can describe these thoughts for me? (I study history and whenever I READ THE WORD KING, I feel anxious and I need to go around the room once). When did it happen? Since when did you start having this condition? How often does it happen? How do these thoughts make you feel (They are unwanted thoughts. It distresses me and makes me anxious.)? Have you tried to resist these thoughts (Yes, I tried but failed)? Do you think that these thoughts are unreasonable and excessive?  Apart from walking arou nd the table do you have any other habits or rituals which you need to carry out every day (He needs to wash hands 10 times a day). Does it cause any trouble? How’ How’s your mood? How’ How’s your appetite? Do you enjoy the things you used to like? Are you in a stable relationship? Are you sexually active? Risk assessment: Have you ever thought about harming yourself or others? Do you see/hear things when no one else is around? Do you think somebody try to put thoughts in your mind or steal from your mind? Have you excessively worried about simple things? Are you perfectionist? Past History: Any medical condition? Particularly thyroid. Any mental or behavioral problems in the past? SADMA? Who do you live with? Do you have many friends? How’ How’s your family? Apart from study do you have other interest? Are you financially secured? Family History: Any medical or mental condition runs in the family?

Diagnosis and Management -  Andrew, from my history I think m ost likely you have an anxiety disorder called obsessive compulsive disorder. Have you ever heard about it? It is a common condition often starting in early adolescence. People with this OCD experience recurrent and persistent thoughts, images or impulses that are intrusive and unwanted. They also perform repetitive and ritualistic actions that are excessive, time consuming and distressing. I would like to refer you to a specialist for assessment. Often the first step in treatment is psychotic treatment. CBT (cognitive behavior therapy): The important part of this therapy is gradual exposure to situations which trigger obsession plus teaching behavior techniques to reduce compulsion and anxiety.

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Medical treatment from psychiatrist: SSRIs Would you like me to organize family meeting? Do you need any support for studying? Prognosis: 20-30% will improve significantly. o 40-50% will have moderate improvement. o 20-40%, they have chronic OCD or o worsening symptoms. People who can have a good prognosis: Good social environment o Clear precipitating event o Episodic symptoms o

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Delayed-Onset PTSD Case: Paul is 55-years of age and a father of four. He presents with difficulties sleeping and concentration. He says that he wakes up in a cold sweat every night after a nightmare and he finds it difficult to sleep because of “anxiety”. The nightmare is always the same: a car accident like the one he experienced 10 years ago. Paul was driving from the hardware shop with his then 8 year old son and suddenly hit on the side of the car and swerved onto the side road. He remembers time “slowly down” as the car was sliding off the road, thinking “this is it” and turning to see his son leaning towards the window. He had wanted to reach out and grab him but had to keep his hands on the wheel and regain control of the car. He said it was probably the most intense and scariest few seconds of his life. No one was injured and at the time Paul felt relieved, thinking for some time after how lucky they were that the car stopped before crashing into the nearby tree. Paul says he has not thought much about the accident until 2 months ago when his son came with his new driver’s license. He says he felt anxious and worried about his son driving, despite telling himself that his son is a safe driver. Every time his son goes out with the car, he has some difficulty concentrating concentrating on anything else and is generally “jumpy” and “on the edge”. Then about a month ago the nightmares started. In the nightmare, he sees the accident, feels time slowing down and sees his son’s head smashed into the window. He wakes up sweating, his heart palpitating, breathing heavily, and in complete panic. He describes the whole experience as “so real” that often in the morning he is overcome with a strong sense of grief. He is not sure whether it is lack of sleep or the dreams but he has been walking around around the home “like a zombie” and not really feeling “quite there”. He finds it difficult to feel positive about any activities and feels numb towards his wife. He describes the situation as unbearable. Task a. b.

Probable diagnosis Management advise (establish SAD, mood, suicidal,

Differential Diagnosis -  Acute stress disorder (constellation (constel lation of abnormal abno rmal anxiety-related symptoms occurring within a 4-weekperiod. Symptoms are grouped as hyperarousal phenomena, avoidance of reminders and intrusive phenomena; management: debriefing and counseling) -  Adjustment disorder (an xiety symptoms within 3 months of response to an identifiable psychosocial stressor; persists for less than 6 months following removal of stressor; non-pharmocological: counseling, relaxation and stress management; pharmacological: short-term benzodiazepines) Diagnosis Type of ANXIETY disorder Physiological component: autonomic o hyperactivity (palpitation, increased HR, dry mouth, upset stomach)

Psychological component: constantly worried, sleeplessness, restless, lack of concentration Constellation of symptoms that persist for 1 month after exposure:  Acute PTSD: duration of sympto ms o 3months Delayed onset PTSD: onset at least 6 o months after stressor Experienced or witness a traumatic event (death, near-death experience, rape, earthquake, natural calamities) with situation with feeling of helplessness and extreme fear Typical distressing recurrent symptoms Recurrent intrusive features – features – recollection,  recollection, o nightmares, flashbacks  Avoidance of events tha t symbolize or o resemble the trauma, detachment, feelings of numbness or withdrawal, guilt Hyperarousal phenomena: exaggerated o startle response, irritability, anger, difficulty with sleeping and concentrating, hypervigilance Management Meditation Meditation and yoga o Lifestyle modification (smoking cessation, o decrease alcohol intake, healthier food, and exercise) Proper sleep hygiene o Recognize what helps patient to  settle best, establish a routine before going to bed, regular daytime exercise and time of arising, avoid daytime naps, avoid strenuous exercise close to bedtime; avoid alcohol and drinks containing caffeine in evening, avoid heavy evening meal and smoking; remove pets from bedroom; avoid lights including poorly screened windows and highly illuminated clocks in the room Sleep promoting adjuvants: warm  bath, warm milk, comfortable quiet sleep setting with right temperature, sex Non-pharmacologic treatment:  meditation, relaxation therapy, stress management; CBT and electromyographic feedback; hypnosis Crisis Intervention Therapy (CBT) o Refer to psychiatrist and psychologist for o counseling (EMDR – (EMDR – Eye  Eye Movement Desensitization and Reprogramming) Social support o Pharmacologic: SSRIs; short-term o benzodiazepines (sleep) o

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Post-traumatic Stress Disorder 2 Case: Your next patient is a 22-year-old man who presents with SOB and poor sleep. SOB occurred at night and relieved by waking up. He had a major vehicular accident 3 months ago and broke 3 ribs. He recovered well. Task a. History (SOB last night, relieved by salbutamol, went for a walk and felt better but returned in the morning  consult; stopped socializing and had no contact with the GF)

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b. History -

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Diagnosis and management

When did it start? Any previous episodes? Did it occur after the motor vehicle accident? Any triggering factor? Any associated features such as chest pain or sweating? How is your general medial health? Any serious medical problems in the past? I know you had a car accident, I’m sorry about it. I’m not asking you to recall the event, but can you please tell a few words about it? Was somebody with you at that time? How is she? Do you have any contact with her? Do you experience any sudden images of the event? Do you try to avoid driving or the place where the incident took place? Do you have any nightmares? Do you feel irritated, angry or guilty about anything pertaining to the incident? How is your mood? Sleep? Appetite? Weight?  Anhedonia? Suicidal Sui cidal ideation: do you think life is worth living? Have you thought of harming yourself or anybody else? Do you see/hear/feel things others cannot or have you had any strange experiences? Whom do you stay with? Do you have a lot of friends? SADMA? ENCOURAGE patient by nodding and showing concern

b. c. d.

Melbourne, recently divorced 3 weeks ago, not on any contraceptives, regular with pap smear, no bleeding disorder; drinking alcohol 3-4 glasses of wine to help with sleep) Physical examination (looks well without eye contact, VS normal, all PE normal) Investigation Diagnosis and Management

Differential Diagnosis Major depression -  Acute stress disorder PTSD Stressors: Death of a loved one Divorce or problems with relationship General life chages Illness or other health issues in yourself or a loved one Moving to a different home or city Unexpected catastrophes Worries about money In teenagers: family problems or conflict, school problems, sexuality issues

Case 2: lady with chest tightness and pain and normal investigation  husband died recently;

Features: 5 symptoms for 2 weeks daily: SAGECAPS (in depression) Sleep o Anhedonia o Guilt o Energy (lack of) o Concentration o Appetite o Psychomotor retardation o Suicidality o Criteria Development of emotional or behavioral o symptoms in response to an identifiable stressor within 3 months of the onset of the stressor Symptoms or behaviors are clinically o significant as evidenced by: marked distress that is in excess  of what would be expected from exposure to the stressor Significant impairment in social or  occupational functioning Stress-related disturbance does not meet o criteria for another specific axis I disorder and is not merely an exacerbation of preexisting axis I or II disorder Symptoms do not represent bereavement o Once stressor has terminated, the o symptoms do not persist for more than an additional 6 months Treatment CBT o Relaxation technique (yoga and meditation) o Healthy diet and exercise, reduce caffeine o Stress management (don’t bottle things up!) o Sleep hygiene o Short-term course of drug treatment is o necessary in persistent or severe case

Case 3: sad woman  anniversary grief

Developmental Disability with Adjustment Disorder

Task

Case: You are a GP and your next patient is a 26-year-old with Down Syndrome living in a support home. There is change in behavior recently and he is very tired. He is afraid to coming to the GP and that is the reason he hasn’t come today as well. Instead, there is a legal carer who has come to see you.

Diagnosis and Management From the chat we had, I think you have a condition called post-traumatic stress disorder. Have you heard about it? It is a type of anxiety disorder where the patient experiences various symptoms and behaviors like recollection, flashbacks, avoidance, sleep problems following a psychologically distressing event which in your case is the MVA you had 3 months before. The symptoms usually come immediately after the event but can be delayed for months or years. I will refer you to a psychiatrist. He will talk and listen to you and will use some techniques to help you come out of this situation  cognitive behavioral therapy.  As you haven’t slept for a few days, he may offer you sleeping pills for a short time but I would advise you to start with sleep hygiene. -  At this stage, you might not ne ed any medication , but if required, the specialist might offer SSRIs. I would like to do a family meeting if it’s okay with you. Family support is very important at this stage. Safe level of drinking. Review. Reading material about PTSD and sleep hygiene. Differentials: anxiety disorder (GAD, adjustment disorder, panic attacks, substance abuse) ADJUSTMENT DISORDERS  Adjustment Disorde r Case: Your next patient in GP practice is 32-year-old Shirley Coombs complaining of SOB. She has recently moved from Sydney to Melbourne with prolonged travel time.

a.

Focused history (started 2 days ago, comes and go, does not change with position, started 4 weeks ago, present at rest, not feeling comfortable, no fever, feels tired, and breathless, drove from Sydney to

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Task a.

b.

History from legal carer (he is not active, tired and doesn’t want to get out of bed recently since last week when his close friend left the home and moved interstate; weight loss; no medications; mood is sad; can’t express in words because is mentally changed) Diagnosis and management

History -

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Confidentiality I understand that you are concerned that you noticed changes in your patient’s behavior and that he is very tired. Could you please explain what you mean by change in behavior? When did it start? Did anything happen around that time when it started? How is is John’s mood? Does he have the capability to express himself? What about his weight? Appetite? Sleep? Has he ever thought of or done something to harm himself? Do you think he has fever? Any chest pain or tummy pain? Does he complain about anything? Any change in bowel motion, color of the stool, or waterworks? Is there any smelly urine, frequency or urgency? Any weather preference especially cold intolerance? Any change in color of the skin?  Any history of getting heart pr oblems? Has he tra veled recently overseas or anywhere else? SADMA? Does he have family? Do they visit him? Does he have other friends in the support home?

DSM IV criteria: Eating amounts of food larger than most people eat in a short period of time Lack of control over eating Eating is followed by compensatory purging by the following mechanisms: Self-induced vomiting o Laxative abuse o Periods of fasting o Excessive exercise o Distorted self-evaluation of body shape and weight Types of bulimia Purging Non-purging: fast, exercise, abuse appetite suppressant Commonly seen in people with depression. They usually have a history of neglect or sexual abuse as a child or young adult. It is commonly seen in well educated high achieving females (compensating mechanism). There is a coexisting history of alcohol abuse, social functioning impairment, along with FHx of mental disorders. 50% of these patients are also diagnosed with a borderline personality disorder. History -

Management Most likely, he has a condition called adjustment disorder. Because he was emotionally attached to his friend, he might have develop these symptoms when he left but it could be depression resulting from hypothyroidism which is common in patient’s with Down syndrome. I would like to run some basic investigations for him including FBE, TFTs, BSL, iron studies, urine MCS, U&E, and LFTs.  At this stage, I want to see him. If he d oesn’t come, then I would like to arrange a home visit. If he has a family, I can arrange a family meeting because he needs a lot of support right now. If you are really concerned, I can refer him to the counselor to help him deal with stress. I would encourage you to engage him in his favorite activities. I would like to review him once the results are back. Reading material. Red flags: for severe depression EATING DISORDERS Bulimia Nervosa Case: You are a GP and your next patient is a 26-year-old female referred by a dentist because of poor dentition, dental hygiene, dental carries and repeated vomiting. Case 2: You are a GP and a 26-year-old computer analyst comes in complaining of self-induced vomiting and some changes in dorsum of hands. BMI is 24 Task a.

b. c.

Relevant History (toothache, filling, self-induced vomiting; don’t want to get fat since teenage; mood: sometimes low  eat more, more depressed; normal sleep Explain Diagnosis Management

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Confidentiality How is your appetite these days? Can you describe your typical daily diet to me? What is your perception about your weight and your body image? Has there been a recent change in your body weight? Do you ever lose control over how much you eat? Do you force yourself to vomit? How frequent? Since when have you been doing this? Have you ever used any meds to lose weight (laxatives, water pill/diuretics)?  Any change to your peri od? LMP? Regular Reg ular cycles? How is your mood recently? Any changes? Do you sleep well? Are you able to perform daily life activities?  Are you in a stable relatio nship? Any sexual sexu al problems? Do you feel your life is worth living? Have you ever thought about harming yourself or others? Do you see/hear/feel things that others don’t? Any strange experiences? Some people have a history of sexual abuse as a child. Do you think it may be related to you? FHx: mental illness? SADMA?

Diagnosis: You have condition called bulimia nervosa which is a part of eating disorders. It is uncontrolled episodic rapid ingestion/intake of large quantities of food in a short period of time. The patient then feels guilty and afraid of gaining weight. They induce vomiting themselves or might use medications/laxatives. It is very common in young females. It is a risky condition. Repeated attempts to lose weight cause a fluctuation in body weight which affects all body systems especially the hormonal balance. It can cause: Irregular periods o Depressed mood o Loss of fluids and minerals o Dental decay o What we need to do is refer you to a psychiatrist. They will confirm the diagnosis first and then start treatment such as CBT and sometimes medication like SSRIs. You need to come for regular follow up. We have support groups for patients with eating disorders.

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Reading materials  Admission  Affecting hormone system o Cardiac disease o Suicide o Hormone changes o

Bulimia Nervosa Case: An 18 year-old-female has been admitted to the hospital in the ED for Diabetic Ketoacidosis. Now she is ready to be discharged. She has normal weight and has a history of binge eating and self-induced vomiting and laxative abuse.

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Support group: Eating disorder foundation Australia

Eating Disorder Case: You are a GP and the mother of a 13-year-old girl has come to you because her daughter has lost weight recently. She does not feel hungry at the time of meal and her periods have not come up to now. Task a.

b.

History from mom (BMI 17, fear of being fat, excessive exercise, constant checking in the mirror, switched to vegetables) Diagnosis and management

Task a. b.

Relevant history Explain the condition to the patient and the management

History -

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When were you diagnosed? Medication? Under control? Last reading of your BSL? Is she on constant follow up by her GP? Diagnosed two years ago. Insulin injections. Missed some doses not regular. Do you check your sugar level everyday? How many times per day? Do you skip meals regularly? Have you ever been admitted to the hospital with complication of DM? When was the last time you visited your GP (2years back. After I’ve been diagnosed I never went back)? Could you please tell me about your daily meal for one whole day (She eats 2-3times a day and large amount of food). Do you feel guilty about your eating habit? What do you do about it (She induces vomiting.)? How often do you vomit? Do you take any laxatives (Yes, 3 times per week)? What do you think about your body weight (Very fat I can’t look at myself in the mirror)? Periods: Are they regular? When was your LMP? Sexual history if she is sexually active? Do you use any contraception? Do you think you could be pregnant? Psycho social history. How’s your general health? SADMA?

Counseling Susan, you are suffering from two conditions: Diabetes and eating disorder most possibly you have bulimia nervosa. Have you heard about it? It’s a common condition common condition in your age group. A person with this disorder eats large amount of food in a short time the loose control and can’t stop eating. After that they induce vomiting to compensate. It’s a very risky situation for you as you are not taking your meals and insulin regularly. You had a complication of diabetes called DKA for which you were admitted to the ED. When you induce vomiting you only loose water and salts from your body but not body fat. It’s dangerous as it can cause damage to your kidney and cause water and mineral imbalance. In the long run, it can affect your heart, lungs, eyes and nerves also. Eating disorder can affect your health adversely, it can cause dental problems, I know your main concern is your body weight. Let me assure you we will help you to achieve an ideal body weight without having to induce vomiting or use laxatives. We will work as a multidisciplinary team. I will refer you to a dietician with whom you can discuss an appropriate diet plan for you. I will also refer you to endocrinologist to adjust your insulin dosage. Psychologist for CBT. With your consent I can arrange a family meeting as family support will be essential. I’d also write a letter to your GP so that he can follow you up regularly and we can prevent complications in the future.

Case: Karen aged 16 years comes to your practice with her mom Julie. Julie tells you that she is quite concerned about Karen’s eating habits. On your questioning questioning to Karen, she tells you that her mom isf forcing her to eat all the time and she is not happy and wants you to help her. Karen is a year 10 student in local school and lives with her parents at home. Task a.

b.

c.

Further history (wants to lose weight because she thinks she is fat; does not socialize with friends; mood okay, no psychotic features) Physical examination (BMI 16.5, BP 100/70, postural drop 15mmHg, HR: 56/minute; T: normal, oxygen saturation, BSL 4.6) Probable diagnosis and Treatment Advise

Common Adolescent Problems  Asthma Obesity Eating disorder (0.3% for anorexia and 1% for bulimia) Early Warning Signs for Eating Disorders Concerned about food, dieting and exercise Frequent weighing Refuse to join other family members in the table Differential Diagnosis Malabsorption Thyroid disorders Diabetes Malignancy  Admission Criteria Electrolyte imbalance Suicidal ideations Severe dehydration Hypothermia (10) Bradycardia (