Empathic listening and addressing patients’ ICE has a positive impact on :

3. Empathic listening and addressing patients’ ICE has a positive impact on : Time efficiency Patient satisfaction Adherence to medication Reduction in distress

5. What factors in your organisation help stressed patients? Doctor starting on time Only having book on day appointments Quiet corner in waiting room Ease of access to doctor Confidentiality

7. How do you avoid ‘Burnout’ Adapt to 5 minute appointments at busy times Pursue a hobby outside medicine Exercise Work alone Maintain a neutral clinicalenvironment

8. OCD Affects 2% population Women greater than men MZ twin concordance identified Commonest in middle age

9. OCD May present with physical symptoms Patients feel pressure of third party thoughts Patients maintain insight 50% also depressed

10. OCD Some patients respond to self help CBT is contraindicated SSRI may help Allow 12 weeks for treatment to work Usually only occurs once in a lifetime

11. People with Borderline Personality Disorder Easily Form Relationships Can be impulsive Tend to be passive Tend to be loners Can be paranoid

13. People with Borderline Personality Disorder Have experienced Parental loss-divorce, death, illness. Commonly from unstable background. Have a FHx of mood disorder, substance misuse Have a history of Childhood trauma/maltreatment.

15. People with Borderline Personality Disorder Require long term drug treatment May respond to CBT Do not respond to psychotherapy Cannot be detained under the MHA

16. Manic Depression Strong twin association May just get mania May be associated with psychosis 5% suicide risk

18. Manic Depression could be confused with: Thyrotoxicosis Psychotic depression Diabetes Schizophrenia

20. Drugs in manic Depression Semisodium valproate is safe in pregnancy Semisodium valproate may cause thrombocytopenia Atypical antipsychotics can raise prolactin Atypical antipsychotics are associated with stroke risk

22. Lithium Is teratogenic Interacts with statins Needs monitoring every 6 months Level best checked immediately after dose Can affect thyroid function

23. People with Manic depression Most have good social support 25% work DVLA revoke licence Few smoke Attract QoF points

24. The following raise suspicion of Anorexia Menstrual disturbance Irritable bowel symptoms Poor dental hygiene Poor insulin control Children with poor growth

25. Anorexia Affects 10% of women Peaks at 15-30 years Is seen in children U&E monitoring necessary BMI < 17.5 5% die

27. Bulimia Cannot be safely managed in primary care CBT may help No role for SSRI Laxatives aid weight loss

28. Chris Williams 5 areas CBT Looks at their thoughts-reasons behind them and how these incorrect assumptions lead to a vicious cycle. 1. Life situation, relationships and practical problems 2. Altered thinking 3. Altered emotions (also called mood or feelings) 4. Altered physical feelings/symptoms 5. Altered behaviour or activity levels.

29. Obsessive Compulsive DisorderNICE Screening tool 2005 Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of but can’t? Do your daily activities take a long time to finish? Are you concerned with orderliness or symmetry? Do these problems trouble you?

30. OCD ICD10 Ob/comp most days 2 week Unsuccessfully resisted thoughts Unpleasant, repetitive, intrusive on ADLs

31. Borderline Personality Disorder Diagnosis –American psychiatric Association >5 of: • 1. Unstable, intense relationships • 2. Impulsivity-in at least 2 potentially damaging areas-spending, sex, subs abuse, eating • 3. Marked mood swings • 4. Intense displays of anger • 5. Recurrent suicidal behaviour/dsh • 6. Unstable image of self • 7. Chronic feeling of emptiness • 8. Frantically try to avoid abandonment • 9. stress related paranoia

32. Manic Depression NICE 2006 Refer if: • Elated episodes >4 days • Recurrent low mood >3 in context of disinhibited/elated behaviour

33. Eating Disorder screening questions • Do you worry excessively about your weight? • Do you feel you may have an eating disorder?

34. Anorexia ICD 10 • The patient’s body weight is consistently 15% lower than that expected for height and age, or body mass index is 17.5 or less. This can be due to either weight loss or failure to gain weight during growth. • Weight loss is caused by the avoidance of foods perceived to be fattening, along with one or more of the following behaviours: self-induced vomiting, purging, excessive exercise, use of appetite suppressants and/or diuretics. • Distorted body image perception driven by an intense, irrational fear of becoming fat, leads to the desire to remain at a low body weight. • Amenorrhoea (abnormal absence of a minimum of three successive menstrual cycles) in women, and loss of libido in women and men. There may be changes in growth hormone, cortisol, thyroid hormone and insulin. • Puberty in girls and boys may be delayed if the onset of anorexia nervosa is pre-pubertal, but once recovery from the illness is made, it will often progress normally.

35. The SCOFF questions* • Do you make yourself Sick because you feel uncomfortably full? • Do you worry you have lost Control over how much you eat? • Have you recently lost more than One stone in a 3 month period? • Do you believe yourself to be Fat when others say you are too thin? • Would you say that Food dominates your life? • *One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia

36. ICD-10 diagnostic criteria for bulimia nervosa • A constant obsession with eating and overwhelming desire for food leads to episodes of eating large amounts of food in short time periods. • There are efforts made to reduce the effect of eating foods perceived as fattening in the form of self-induced vomiting and other purging techniques, alternating episodes of calorie restriction, using appetite suppressants, thyroid preparations or diuretics. People with diabetes may refrain from using their insulin treatment. • There is an intense fear of becoming fat, which leads to the desire to reach a specific body weight much lower than is considered normal or healthy for height and age. In many cases, bulimia follows an episode of anorexia nervosa, although the period of time between the two disorders may vary considerably.

37. Suicide assessment • P problems >1 month • A alone when attempted • T >three hours preparation • HO feels Hopeless • S sad on most days