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Psychiatry in General Practice

Psychiatry in General Practice. Dr. Achal Bhagat MBBS MD MRCPsych APOLLO HOSPITAL SAARTHAK. Psychiatric Disorder is common. 25% of general population 40-50% of general practice population Psychosocial Issues more common in women Depression becoming more common in younger men.

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Psychiatry in General Practice

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  1. Psychiatry in General Practice Dr. Achal Bhagat MBBS MD MRCPsych APOLLO HOSPITAL SAARTHAK

  2. Psychiatric Disorder is common • 25% of general population • 40-50% of general practice population • Psychosocial Issues more common in women • Depression becoming more common in younger men

  3. HOW IS PSYCHIATRIC DIAGNOSIS DIFFERENT? • No External Validation • What is Normalcy? • Culture • Interview is a key skill

  4. HOW DO YOU ARRIVE AT PSYCHIATRIC DIAGNOSIS? • ESTABLISH RAPPORT • OBTAIN INFORMATION • ASSESS FOR PSYCHIATRIC SIGNS • COMPARE PRESENT FUNCTIONING WITH DEVELOPMENTAL STAGE GOALS • ANALYSE

  5. Diagnosis: When to explore further? • Unexplained multiple somatic symptoms • Multiple visits • Biological Symptoms • Irritability • Hopelessness • Fatigue • A depressed look

  6. KEY DISORDERS • MINOR PSYCHIATRIC DISORDERS • MAJOR PSYCHIATRIC DISORDERS

  7. MAJOR DISORDER • MOOD DISORDER • SCHIZOPHRENIA

  8. MINOR DISORDERS • ANXIETY • Apprehension about future, On the edge, Somatic Symptoms, Avoidance • DEPRESSION • Sustained Change of Mood, Inability to enjoy, Negative Cognitions, Lack of Interest, Sleep and Appetite Disturbance • OBSESSIVE COMPULSIVE DISORDER • Repetitive intrusive thoughts recognized to be absurd have to be controlled by either doing something or avoiding something • DISORDER OF SEXUAL FUNCTION

  9. DIAGNOSING PSYCHIATRIC DISORDER • APPEARANCE AND BEHAVIOR • SPEECH • MOOD • THOUGHT • PERCEPTION • COGNITION

  10. HOW TO ANALYSE? • WHAT ARE THE AREAS OF DISTURBANCE? • IN WHAT AREA IS THE KEY DISTURBANCE? • WHAT AREA DID THE DISTURBANCE START FROM? • WHAT AREA IS THE MOST DISTRESSING? • ARE THERE ANY CAUSATIVE RELATIONSHIPS?

  11. HISTORY • I/D • CHIEF COMPLAINTS IN CHRONOLOGICAL ORDER • HOPI • SPONTANEOUS CHRONOLOGICAL ACCOUNT • COMPLETE THE SYNDROME • NEGATIVE HISTORY • TREATMENT HISTORY

  12. HISTORY • PAST PSYCHIATRIC HISTORY • PAST MEDICAL HISTORY • FAMILY HISTORY • PERSONAL HISTORY • BIRTH • CHILDHOOD • ADULT • RELATIONSHIPS WORK LEISURE • PRESENT LIVING CIRCUMTANCES • PRESENT FAMILY

  13. SPEECH • REACTION TIME • QUANTITY • COHERENT • COMPREHENSIBLE • PROSODY

  14. MOOD • QUALITY • SUBJECTIVE • OBJECTIVE • RANGE • REACTIVITY • INAPPROPRIATE / INCONGRUENT

  15. THOUGHT • FLOW • FORM • CONTENT • OVERVALUED IDEAS • DELUSIONS • OBSESSIONS

  16. PERCEPTION • ILLUSIONS • HALLUCINATIONS • BODY IMAGE • DEREALISATION/ DEPERSONALISATION

  17. COGNITIVE FUNCTIONS • ORIENTATION • ATTN/CONC • MEMORY • INTELLIGENCE • JUDGEMENT • ABSTRACT THINKING • INSIGHT

  18. BASICS • ALWAYS TRY TO EXPLAIN ALL SYMPTOMS WITH ONE DIAGNOSIS/HYPOTHESIS • BUT CO-MORBIDITY IS A REALITY • CONSIDER A DIAGNOSIS OF PERSONALITY DISORDER IF THERE IS NO CLEAR CUT ONSET/ THERE ARE PATTERNS IN INTER PERSONAL RELATIONSHIPS

  19. BASICS • RULE OUT LEARNING DISORDER • RULE OUT ORGANIC DIAGNOSIS • RULE OUT SUBSTANCE ABUSE • RULE OUT MOOD DISORDER • RULE OUT SCHIZOPHRENIA • CONSIDER MINOR PSYCHIATRIC DISORDER

  20. WHAT WORKS? • MEDICINE • PSYCHOLOGICAL TREATMENTS • SOCIAL SUPPORTS

  21. How to explore? • Active Listening • Explore triggers and patterns in psychosocial context • Do not ask why • Do not suggest that symptoms are functional • Look out for key symptoms

  22. Depression is treatable • Antidepressants and not benzodiazepines • Adequate dosages • Adequate time • When to refer?

  23. Which antidepressant? • Conventional • Least side effects • Same as the one that worked last time • Different from the ones which have already been tried without a positive result • Explore causes of non response

  24. Is psychotherapy possible at the level of general practice? • Yes • What methods? • Cognitive Behaviour Therapy • Supportive Therapy

  25. Cognitive Behaviour Therapy • We Think • We Feel • We Act • If we change the way we think we can change the way we act

  26. How to change thinking? • Identify negative thoughts • Identify patterns in them • Learn methods of challenging the patterns • Replace these with lesser negative thoughts

  27. Physician heal thyself • What are my needs? • What are my need fulfilling activities and how much time do I spend in trying to do them? • What are the obstacles? • What can I do about the obstacles?

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