I am an NHS Psychiatrist AMA

[ipredictariot5]

There has been so much in the news this week about the mental healthcare of the man who killed the three people in Nottingham. If anyone wants to
ask any questions about this or psychiatry in general fire away

Do you have any training or experience any patients who suffer from maladaptive daydreaming?

I can only comment in a general way but challenging your dad won’t fix the psychosis and we tend to advise going along with the symptoms whilst reassuring them and try to engage in other activities so the psychosis isn’t so front and centre. Paychosis can be very frightening and reassurance and comfort helps
sorry to hear your dad isn’t under services from what you say he sounds like he should have regular reviews

Prader Willi plus poor mental health is an incredibly difficult set of problems to manage. If you are being refused assessment in NHS I advise complaining. PALS is often the best route ( I know there is a theme on me saying complain but in a broken NHS the way to get care sadly is often via PALS )
also try the Prader Willi Assocation who can be very supportive and sign post
haivng said all that CBT is the most effective intervention for managing emotions and anxiety and I would hope he would find it useful

EUPD is a diagnosis that may explain symptoms but does not necessarily help you access the care you need which is generally paycholgy and medication can be used to help symptoms
CBT/ DBT and often group based helps some areas have specific PD ssrvices too
if you want to do more reading the best book I have ever read is ‘I hate you don’t leave me’ which I think should be compulsory reading for all psychiatrists

I try to be patient centred and work out collaboratively how best to understand their distress. I try not to impose a medical model. But I am trained to think that way and it is helpful in formulating a patients problem for me

@FloofCloud

Sorry to chip in, but given that ND is hereditary to a certain extent, do you think your PILs’ cognitive inflexibility might be autism/ADHD?

I am not sure it is right that an exam board would not accept a private diagnosis as that is how loads of people are diagnosed now. My advice would be to always get the assessment done by a consultant psychiatrist so it is not challenged

I definitely think neurodiversity is under diagnosed and should be actively looked for. To have an understanding of why you might feel you don’t fit in/ achieve educationally/ hold down work/ relationships can be life changing. There are support mechanisms and legal rights in education and work with a diagnosis
in terms of the degree of disability some people will be relatively unaffected, others it can be v disabling
narcissism is a term I do not use - in psychiatry it tends to be reserved for a v small number of people who fit the criteria for a narcissistic personality disorder

All psychiatrists have psychological training
my role I would say is to make diagnosis and also think very hard about whether there is a physical health disorder explaining or worsening symptoms. I also lead a team of other professionals and have the ability to use the mental health act. And yes I prescribe medication but many illnesses need medication
psychology is where the healing happens for many people and we do not have enough of them or available in the right timescale. I had time off with depression myself and had CBT and I found it amazing

Early onset is much more likely to run in families than later onset

Thanks. Yeah I think he should be under regular reviews, especially with the lithium, but when I challenged it they said the mental health services are so busy in his area that they can only see people who are actively suicidal. So looks like we will have wait until we get back to that stage to get any help. He's been sectioned several times in the past.

The prognosis is not as bad especially if picked up early. Some patients will have one psychotic episode and never again. Others will have relapses over their lives. About 15% have chronic symptoms really impacting on their lives
other factors are compliance with treatment and whether the patient uses alcohol and drugs land has insight into how to stay well there is also a specialised CBT for psychosis to help people live with symptoms and maintain good function
so I would certainly encourage people at the start of an illness to maintain their life
plans. There are people in all sorts of professions with personal experience of psychosis

The MH of young people is a real worry, so
many factors, world events,’academic pressures, their lives online and the pandemic had a massive impact
however young people do have resilience and do get better. This generation also drinks less that helps their MH no end.
I have adult children and I really worry about them too. Boosting self esteem and ambitions and positive adult relationships all help

If you could design/re-design services for people in need, what would you prioritise? Resources will always be a factor in life but if we could do the best with what we have what might a successful service look like for patients and professionals?

There is lots of well done academic work on neurotransmitters/ serotonin and the relationship to depression
my experience with SSRIs is there are some people who do need them long term, especially if you have tried to come off them and become unwell. You know yourself best so go with what feels right for you

It’s a real bug bear of mine that women with no history of MH problems seek help with low mood and anxiety at menopause and get given antidepressants or dismissed when they need HRT. I am always boring colleagues going on about it!

Re ADHD screening- my Ds has NHS dx of ASD & Clinical Anxiety. He also has an Ed Psych dx of Dyslexia & Dyscalculia. I suspect he also has ADHD. He would like an assessment & to try meds if it's positive. GP says NO ('waiting list closed as over 3 yrs'). I'm in Scotland. Ds is 19. How to arrange this?

And this is why my sibling and I (in our 50s) are shitting ourselves as our mum was diagnosed in her 50s with Alzheimer’s, with no known family history

Thank you so so much @ipredictariot5 for this thread.

I have had anxiety as long as I can remember but it came to a head in 2012 with severe panic attacks and a prolonged spell of agoraphobia.

I was assessed at the capio nightingale in London and put on Sertraline 50mg, beta blockers when required and a long course of CBT.

I still take Sertraline 50mg so that’s 12 years of SSRIs.

i just read your criteria for ADHD and in fact I scored very highly on it. I wonder if I have ADHD and if so was the anxiety related to that? And also if Sertraline is an effective drug for ADHD or if I might be better trying something else.

PS my issues with Sertraline are zero libido, I haven’t cried for 2 years even when I really want to, and restless legs.
My anxiety is very much under control.

Do you think we will one day look back on what we are doing to ‘trans’ children and call it abuse?

You've mentioned CBT in many of your responses. What do you think about psychodynamic and psychoanalytic therapies? Are you aware of the growing evidence-base that shows their longterm efficacy is often better than CBT.

Thank you very much for answering.
I am tapering off venlafaxine at the moment. They expect me to do it over three weeks and don't believe me when I say it won't work.
What is hyperbolic tapering @TrentCrimmIsHot and please do you have any links to groups?

I can’t really comment on follow up - there is pressure to discharge due to volumes of patients at times but generally I have been able to maintain follow up when I think appropriate. However as many conditions are life long I tend to discharge if people are well and stable and see again if they worsen
collateral histories are really important and I always try to seek them with consent of the patient ( or without if the patient is so unwell they do not have capacity )

How do you feel about the dismissive attitude towards older, effective medications, in favour of exciting new drugs with exciting new side effects?

Although I don't take them any more, I'm in online patient groups for people who use MAOIs. There's some evidence that these drugs are more effective than modern antidepressants, and certainly that they're more effective for people with certain subtypes of illness. There are some for whom no drug other than an MAOI works.

And yet for so many of us, it took decades before any doctor would try an MAOI, and people have been through complex polypharmacy with powerful antipsychotic and mood stabilisation treatment, ECT, ketamine treatment, and other extreme therapies, before even a simple trial of phenelzine or tranylcypromine would be considered. We're all aware of the small but manageable risk of interactions, how to prevent them and what to do if it happens, and it seems strange to us that psychiatrists prefer screwing up our metabolisms and giving us diabetes with atypical antipsychotics, or wiping our memories with electric currents through the brain, to trying an effective but older antidepressant with a couple of minor dietary restrictions.