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 DEPRESSION OBSESSIVE COMPULSIVE DISORDER
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?