Psychiatry in General PracticeDr. 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

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

HOW DO YOU ARRIVE AT PSYCHIATRIC DIAGNOSIS? ESTABLISH RAPPORT OBTAIN INFORMATION ASSESS FOR PSYCHIATRIC SIGNS COMPARE PRESENT FUNCTIONING

WITH DEVELOPMENTAL STAGE GOALS

ANALYSE

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

KEY DISORDERS

MINOR PSYCHIATRIC DISORDERS MAJOR PSYCHIATRIC DISORDERS

MAJOR DISORDER

MOOD DISORDER SCHIZOPHRENIA

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

DIAGNOSING PSYCHIATRIC DISORDER APPEARANCE AND BEHAVIOR SPEECH MOOD THOUGHT PERCEPTION COGNITION

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?

HISTORY

I/D CHIEF COMPLAINTS IN

CHRONOLOGICAL ORDER HOPI SPONTANEOUS CHRONOLOGICAL ACCOUNT COMPLETE THE SYNDROME NEGATIVE HISTORY TREATMENT HISTORY

HISTORY

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

SPEECH

REACTION TIME QUANTITY COHERENT COMPREHENSIBLE PROSODY

MOOD

QUALITY SUBJECTIVE OBJECTIVE RANGE REACTIVITY INAPPROPRIATE / INCONGRUENT

THOUGHT

FLOW FORM CONTENT OVERVALUED IDEAS DELUSIONS OBSESSIONS

PERCEPTION

ILLUSIONS HALLUCINATIONS BODY IMAGE DEREALISATION/

DEPERSONALISATION

COGNITIVE FUNCTIONS

ORIENTATION ATTN/CONC MEMORY INTELLIGENCE JUDGEMENT ABSTRACT THINKING INSIGHT

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

BASICS

RULE OUT LEARNING DISORDER RULE OUT ORGANIC DIAGNOSIS RULE OUT SUBSTANCE ABUSE RULE OUT MOOD DISORDER RULE OUT SCHIZOPHRENIA CONSIDER MINOR PSYCHIATRIC

DISORDER

WHAT WORKS?

MEDICINE PSYCHOLOGICAL TREATMENTS SOCIAL SUPPORTS

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

Depression is treatable

Antidepressants and not benzodiazepines Adequate dosages Adequate time When to refer?

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

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

Cognitive Behaviour Therapy

We Think We Feel We Act If we change the way we think we can

change the way we act

How to change thinking?

Identify negative thoughts Identify patterns in them Learn methods of challenging the patterns Replace these with lesser negative thoughts

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?