6- Therapeutics commonly used in psychiatry (Non-pharmacological)

Question 1

ECT

Answer 1

Electroconvulsive therapy (ECT) is the passage of a small electrical current through the brain with a view to inducing a modified epileptic seizure which is therapeutic. **

Question 2

background around ECT

Answer 2

• One of the most effective treatments for severe depression (70-80% response rate)
• Most patients experience improvements within 2 weeks
• 6-12 treatments given twice weekly

Question 3

pathophysiology behind ECT

Answer 3

• Not understood
• Induced a small seizure
• Affects multiple CNS components including
  o Hormones
  o Neuropeptides
  o NT
  o BBB

Question 4

indication for ECT

Answer 4

Electroconvulsive therapy is a treatment for severe psychiatric illnesses, including:

• Severe depression which is resistant to multiple antidepressants
• Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/suicide risk)
  E.g. not being able to drink or eat
• Catatonia

Question 5

side effects of ECT

Answer 5

• Short term memory loss
• Retrograde amnesia (memory loss immediately before/after ECT)
• Post ECT headache
• Brief confusion/drowsiness following admin of anaesthetics

Question 6

contraindications of ECT

Answer 6

• MI/ VTE <3 months ago
• Unstable fracture
• Raised ICP e.g. intracranial bleed of SoL
• Stroke
• Severe anaesthetic risk e.g. severe CV or resp disease
• History of status epilepticus

Question 7

Risks of ECT

Answer 7

• General anaesthetic e.g. airway issues
• Small risk that the patient will not respond to the treatment

Question 8

capacity and ECT

Answer 8

Capacity and ECT

• A patient has the right to refuse ECT treatment if they have the capacity to make this decision, even whilst they are detained under the Mental Health Act.
• If a patient lacks capacity to consent ECT may be administered under the Mental Health Act (section 58A/62)

Question 9

Mental Capacity Act and ECT

Answer 9

ECT may be administered under the Mental Health Act (section 58A/62)

- 58A- Will need a second opinion doctor (SOAD) to assess and agree ECT is appropriate

- 62- if patient requires emergency treatment with ECT to save persons life or prevent serious deterioration – allows aptient to have ECT whilst waiting for an SOAD

Question 10

For a patient to be considered to have capacity, they must be able to:

Answer 10

1. understand the treatment
2. retain the information given in order to be able to make a decision about treatment
3. weigh up the risks and benefits of treatment
4. communicate back a decision regarding treatment

Question 11

How to explain what ECT is to a patient

Answer 11

“Electroconvulsive therapy, also known as ECT, is a psychiatric treatment in which a patient is put to sleep and a small amount of electrical energy is directed toward the brain which induces a controlled minor seizure. This is thought to alter chemical imbalances in the brain, therefore reducing the severity of psychological illness.”

Question 12

the procedure: before

Answer 12

• A pre-procedure assessment is carried out by an anaesthetist:
  1) Physical examination
  2) Blood tests
  3) ECG
  4) Chest radiograph
• The patient is required to be nil by mouth for 6 hours before the procedure (same as an operation).
• ECT is carried out in an ECT suite. This may be in a general or psychiatric hospital setting.
• A short-acting anaesthetic is administered by an anaesthetist.
• A muscle relaxant (e.g. suxamethonium) is administered in order to minimise the risk of harm to the patient during convulsions.
• The patient is attached to an EEG machine for continuous monitoring of brain activity.

Question 13

the procedure: during

Answer 13

ECT is carried out by a psychiatrist and can be delivered unilaterally or bilaterally

• A small amount of electrical energy is directed through the electrodes towards the brain.
• The electrical charge lasts around 5 seconds.
• The electrical energy to the brain induces a controlled seizure which lasts around 20 seconds.
• Evidence of this may include visible muscle contractions/spasms and eyelid fluttering. Often the seizure is not visible clinically and can only be identified on the EEG.

Question 14

Unilateral ECT

Answer 14

• A unilateral ECT electrode is placed on the non-dominant hemisphere of the brain.
• Unilateral ECT is generally associated with fewer side effects but is less effective than bilateral ECT, therefore, more treatments are required at an increased frequency.
• Considered if cognitive side effects suffered with previous ECT or in the elderly

Question 15

bilateral ECT

Answer 15

more commonly used due to increased efficacy. Two electrodes are placed on either side of the temples.

Question 16

the procedure: after ECT

Answer 16

When ECT is complete the patient will wake up in the recovery room having no memory of the procedure. They may experience some side effects as outlined below but these should be short-lived.**

Question 17

define psychological therapies

Answer 17

“A form of treatment based on the systematic use of a relationship between therapist and patients (as opposed to pharmacological or social methods) to produce changes in cognition, feelings and behaviour”

Question 18

Psychotherapy vs counselling

Answer 18

• Counselling offers non-judgemental support and encourages the person to clarify and priorities current problems and to finds solutions
  o It does not usually explore the therapeutic relationship (as in psychodynamic psychotherapy)
  o Help people overcome immediate crises e.g. job loss, bereavement or relationship problems
• Psychotherapy helps people with more long-standing problems of a serious nature
  o Psychotherapists therefore require a long and specialised training and continue to receive regular supervision from colleagues and their clinical work

Question 19

Who is not suitable for psychotherapy

Answer 19

• Patients with psychosis
• Patients with serious dependence on illegal drugs

Question 20

Main models of psychotherapy

Answer 20

• Supportive/counselling therapy
• Cognitive Behaviour Therapy
• Psychodynamic (based on the work of Freud)
• Family/systemic therapy

Question 21

principles of psychotherapy

Answer 21

• Personality and psychology is shaped by past experience – ubiquitous
• Childhood experience interacts with genetic tendency to influence adult personality and mental health
• Aetiology of mental distress is not ‘gene or environment’ but how these interact, esp. during developmental years e.g. epigenetic changes
  o Especially sensitive periods e.g. adolescent years
• Different therapies emphasise different parts of the complex picture of the interactions of cognitions, affect and the body

Question 22

settings used for pyschological therapy

Answer 22

• One on one
• In groups
• Hospital, day centres, residential settings, online

Question 23

psychodynamic therapies

Answer 23

1) Classical psychoanalysis
2) psychodynamic psychotherapy
3) CBT
4) Behavioural therapies
5) Cognitive therapies
6) pyschoeducation
7) Interpersonal therapy
8) Group/ systemic therapy
9) Eye movement desensitization and reprocessing (EMDR)
10) Dialectical behavioural therapy (DBT)

Question 24

classifcal psychoanalysis

Answer 24

• Freuds approach to psychoanalysis
• Indication
  o Dissociative disorders
  o Somatoform disorders
  o Psychosexual disorders
  o Certain PD
  o Chronic dysthymia
  o Recurrent depression
• Long term, intensive treatment (Most days of the week over many years)
• Key therapeutic tools:
  1. Transference: The patient re-experiences the strong emotions from early important relationships, in their relationship with the therapist. When the current emotions are positive it is said to be positive transference and vice versa for negative emotions.
  2. Counter-transference:The therapist is affected by powerful emotions felt by the patient during therapy and reflects what the patient is feeling.
• Goal: to restructure entire personality
• Not usually available on NHS

Question 25

psychodynamic psychotherapy

Answer 25

• Less frequent treatment than classical psychoanalysis (once or twice weekly session of 50 mins, from 4 months to a year or more)
• Goal: a more focused therapy aiming for circumscribed character and behaviour change

Question 26

indication for psychodynamic psychotherapy

Answer 26

o Patients suffering with recurrent and chronic inter-personal relationships
o Psychological conflict or alienation
o Can also contribute to the management of: PD, depression, ED, some anxiety disorders

Question 27

rationale behind psychodynamic psychotherapies

Answer 27

The therapy centres on the evolution of conscious understanding, primarily by interpreting what the patient does and says during a therapy session and through the inter-subjectivity of the therapeutic relationship. It thus addresses issues of transference and psychological defence mechanisms.
o Presenting problem is understood in light of past experience e.g. childhood trauma or deficiency and the dynamics of the inernal world

Question 28

psychodynamic psychoanalysis procedure

Answer 28

• Procedure: unstructured and the therapist takes a position of benign neutrality, enabling the patient to freely express things within the safe boundaries of ththerapy
  o Therapists will have had their own personal therapy in order that they are more aware of the emotional issues that they (compared to the patient) bring into the relationship

Question 29

aim of psychodynamic psychoanalysis

Answer 29

resolution of unconscious conflict and may not primarily or only be focused on achieving symptomatic change
- An increased understanding of personal problems may initiate symptomatic change, which continues long after termination of formal treatment

Question 30

Cognitive behavioural therapy

Answer 30

• Most common form of psychotherapy: combines behaviour and cognitive therapies
• Developed by Aaron Beck
• Explicit with a shared formulation
• Structure is important

Question 31

indication for CBTT

Answer 31

o Mild -moderate depression
o Eating disorders
o Anxiety disorders
o BPAD
o Substance misuse disorders
o Schizophrenia
o Other psychotic disorders adjunct to pharamcolotherapy
o Chronic medical conditions e.g. fibromyalgia, chronic fatigue syndrome or chronic pain)

Question 32

rationale behind CBT

Answer 32

Treatment is based on the idea that the disorder is not caused by life events, but by the way the patient views these events (Fig. 12.1.2). It is a short-term, collaborative therapy, focused on the ‘here and now’, the goals of which are symptom relief and the development of new skills to sustain recovery. Some people hold unhelpful core beliefs or ‘silent assumptions’ that they learn from early, traumatic life experiences. These people are more vulnerable to depression. When exposed to stress at a later date, these core beliefs are activated and they have negative automatic thoughts or cognitive distortions

Question 33

aim of CBT

Answer 33

• Aim: initially to identify and challenge individuals in their automatic negative thoughts and then to modify any abnormal underlying core beliefs. The latter is important in reducing risk of relapse

Question 34

mode of devlivery of CBT

Answer 34

• Mode of delivery: individual, group or as self-help via books or online

Question 35

Behavioural therapies

Answer 35

• Learning theory and particularly operant conditioning
  o States that the behaviour is reinforced if it has a positive consequence for the individual and prevents any negative consequences

Question 36

example behavioural therapies

Answer 36

o Relaxation training
o Systemic desensitisation
o Flooding
o Exposure and response prevention
o Behavioural activation

Question 37

behavioural therapies procedure

Answer 37

o Uses techniques usually involving some form of exposure to reduce avoidance and permit habituation

Question 38

indication for behavioural therapy

Answer 38

o Especially important for the treatment of anxiety disorders
 Panic
 Social
 OCD
 PTSD
o ED and depression

Question 39

Cognitive therapy

Answer 39

• Addresses the role of dysfunctional thoughts and beliefs in producing and maintaining undesirable emotional states and behaviours
• Aim: symptomatic change

Question 40

key features of cognitive therapy

Answer 40

• Key features
  o Structured
  o Problem-orientated
  o Time-limited (between 6 and 15 weekly sessions each an hour)

Question 41

cognitive therapy procedure

Answer 41

• An explicit formulation of the origin and maintenance of the patients problem is developed in collaboration with the patient
• This guides homework tasks
   Experimenting with new behaviours, identifying and challenging negative thoughts, collecting evidence for or against beliefs
• Utilises behavioural techniques to complement and enhance cognitive approaches

Question 42

Psychoeducation

Answer 42

• Psychoeducation (PE) is the delivery of information to people in order to help them understand and cope with their mental illness.
• It is usual to inform the patient of: 1) the name and nature of their illness; 2) likely causes of the illness, in their particular case; 3) what the health services can do to help them; and 4) what they can do to help themselves (self-help). PE may take place individually or in groups, and will usually take the person’s own strengths and coping strategies into account.

Question 43

Interpersonal therapy (IPT)

Answer 43

• Time-limited weekly therapy
• Indication: depression , recently expanded to including ED
• Rationale: Uses the link between the onset of depressive symptoms and current interpersonal problems as a focus for treatment
  o Basically tries to find a connection between depression and their current circumstance e.g. divorce, redundancy
  o Does not make assumptions about aetiology and does not dwell upon enduring aspects of the personality
  o Addresses current relationships
• Procedure
  o Therapists are active and supportive

Question 44

Group and family / systemic therapy
family therapy but doesn’t have to be.

Answer 44

• Roots in anthropology and cybernetics
• Indication
  o Most commonly used in children
  o ED (particularly with younger anorexic patients)
  o Adjunctive treatment in schizophrenia
• Rationale: They do not view symptoms or insight as an appropriate focus for treatment intervention, but instead target the system that generates the problematic behaviour. This is classically seen in a family unit, where each family member is viewed as a component of the system, and the patient’s problem is generated (and maintained) by the system’s malfunctioning
• Procedure
  o Techniques of suggestions or emphasising the positive value of symptoms for the whole family as methods of bring about change tot eh family system
• Group therapy very widely practised- Group analytic therapy, CBT, and other therapies adapted to practise in a group format.
• Family/systemic therapy . Unfortunately absent from some psychotherapy departments. Mainly find in Child mental health depts.
• Systems theory usually the basis of

Question 45

Eye movement desensitization and reprocessing (EMDR)

Answer 45

• EMDR is a psychotherapy treatment that aims to help patients access and process traumatic memories with the goal of emotionally resolving them.
• It is an effective treatment for PTSD.
• It involves the client recalling emotionally traumatic material while focusing on an external stimulus. The stimulus usually involves the therapist directing
  the patient’s lateral eye movements by asking them to look one way and then another or follow their finger

Question 46

Dialectical behavioural therapy (DBT)

Answer 46

Dialectical behaviour therapy or DBT is based on CBT, with greater focus on emotional and social aspects.
* DBT is used for individuals with borderline PD.
* The therapy adopts components of CBT and also provides group skills training to provide the individual with alternative coping strategies (rather than deliberate self-harm) when faced with emotional instability.

DBT has proven to be effective for treating and managing a wide range of mental health conditions, including:
Borderline personality disorder (BPD).
Self-harm.
Suicidal behavior.
Post-traumatic stress disorder (PTSD).
Substance use disorder.
Eating disorders, specifically binge eating disorder and bulimia.
Depression.