7b - Psychological Interventions (06.03.2020)

Question 1

What is a panic attack?

Answer 1

A discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feeling of impending doom.
- During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of “going crazy” or losing control are present.

Question 2

Agoraphobia

Answer 2

• Develops as a complication of panic attacks
• Agoraphobia may arise by the fear of having a panic attack in a setting from which escape is difficult (or embarrassing)
• As a result, sufferers of agoraphobia avoid public and/or unfamiliar places, especially large, open, spaces where there are few ‘places to hide‘ or prevent easy escape

Question 3

Biomedical model

Answer 3

• aims to classify mental disorders on the basis of objective markers

Question 4

Psychological Therapy

Answer 4

Goal of all psychotherapy is to help people change maladaptive thoughts, feelings, and behavior patterns

Major schools:
Psychodynamic
Behavioural
Cognitive

Question 5

Psychodynamic therapy

Answer 5

• Personality is made up of three parts (i.e., tripartite): the id, ego, and super-ego:
• conflict between the three
• Sigmund Freud
• childhood shaping personality

Question 6

Behaviour Therapies

Answer 6

Behavioural approaches believe that:

• Maladaptive behaviours are not merely symptoms of underlying problems
  
  • The behaviours are the problem
• Problem behaviours are learned in the same ways normal behaviours are

Question 7

‘Phobia’ Development

Answer 7

• Conditioning

Question 8

Two-factor theory of maintenance of conditioned associations e.g. fear

Answer 8

• the thing that scares you -> high fear, aanxiety

- avoid the thing that scares you -> fear is reduced -> tendency to avoid it is strengthened

Question 9

Behaviour Therapies

Answer 9

• Exposure Approach is influenced by both classical and operant conditioning approaches:
• E.g. In someone who is scared to drive again after a car accident
• Treat phobias through exposure to the feared CS (i.e. car) in the absence of the UCS (i.e. accident)
• Response prevention is used to keep the operant avoidant response from occurring
• Highly effective for reducing anxiety responses
• exposure to reduce anxiety response
• GRAADUAL desensitisation

Question 10

Classical vs operant conditioning

Answer 10

Classical conditioning: associate an involuntary response and a stimulus

Operant conditioning: associate a voluntary beahvior and a response (e.g. animal taught to press something to feed themselves)

Question 11

Cognitive Theory

Answer 11

• there is in-between appraisals etc. stimulus and response
• stimulus -> cognition -> response
• emotional response is dependant on how you appraise the situation.

Question 12

Clark’s (1986) cognitive theory of panic

Answer 12

• Individuals with panic interpret certain bodily sensations in a catastrophic fashion
• Sensations (esp. those involved in normal anxiety responses e.g., palpitations, breathlessness, dizziness) are considered to be a sign of impending physical or psychological disaster
• e.g. palpitations -> “I’m having heart attack”

There is a vicious cycle:

internal/external trigger -> percieved threat -> anxiety p> physical. cognitive symptoms -> misinterpretation -> anxiety….

• other source: individuals who experience recurrent panic attacks do so because they have an enduring tendency to misinterpret benign bodily sensations as indications of an immediately impending physical or mental catastrophe.

Question 13

CBT for Cardiac Anxiety

Answer 13

Treatment comprised of:

• Psychoeducation
• Relaxation techniques
• Cognitive restructuring
• Behavioural experiments
• Graded exposure
• Relapse prevention

Question 14

Core features of Cognitive Behavioural Therapy

Answer 14

• Focuses on problematic beliefs and behaviours that maintain disorders (‘here and now’ rather than original causes).
• Goal oriented i.e. Specific and measurable
• Collaborative relationship between therapist and patient
• Brief (8-16 sessions)
• ‘Scientific’ approach e.g. Collecting data, testing hypotheses

Question 15

Depression

Answer 15

• ICD-11, WHO
  A depressive episode is characterized by:
• a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks
• Other symptoms include:
  difficulty concentrating, feelings of worthlessness
  excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide,
  changes in appetite or sleep,
  psychomotor agitation or retardation,
  reduced energy or fatigue.

Question 16

Treatment for depression

Answer 16

• 54% of adults show improvement after antidepressant medication
• 35-40% of adults show improvement after psychotherapy
• 62% (66% in CBT) show improvement after psychotherapy
• 43% of adults show improvement in care-as- usual groups of psychotherapy trials
• 53% of adults with ‘untreated’ depression show improvement after 12 months.

Many people benefit from treatment but there is also a large number that don’t. We don’t know yet who will reply best for the specific form of treatment.q

Question 17

Is psychotherapy effective?

Answer 17

• A review of 257 meta-analyses showed that the majority (80%) reported a significant effect on outcomes (Dragioti et al, 2017)
• Currently, strongest evidence for CBT
• Comparative trials of different psychotherapies show differential effects are small
• Disorder specificity

Question 18

NICE guidelines fro CBT as a first line treatment

Answer 18

Mild to moderate depression
	Social anxiety 
	PTSD
	Generalised anxiety disorder
	OCD
	Bulimia
	Panic disorder and specific phobia 
        Schizophrenia
	(see NICE at www.nice.org.uk)

Question 19

NICE: Case identification and recognition of depression

Answer 19

Be alert to possible depression
- Particularly in people with a past history of depression or a chronic physical health problem with associated functional impairment.

Consider asking people who may have depression two questions, specifically:

• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

Question 20

What two questions should you consider asking people who might have depression?

Answer 20

• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

Question 21

NICE drug treatment for depression

Answer 21

Do not use antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because the risk–benefit ratio is poor

Consider antidepressants for people with:

• a past history of moderate or severe depression or
• subthreshold depressive symptoms present for a long time or
• subthreshold depressive symptoms or mild depression that persist(s) after other interventions.

Question 22

Antidepressants: Placebo?

Answer 22

• Kirsch et al (2008) obtained files from the U.S. Food and Drug Administration (FDA) containing data from trials that had not been published, as well as those data from published trials
• Kirsch’s analyses of the FDA data showed that the difference between antidepressant drugs and placebos was not clinically significant, according to the criteria used by NICE

-> when you come to the severe range where you see more difference between new drug and….??????

• A recently published review of 522 studies covering 116,477 patients in total.
• After 8 weeks of treatment, all 21 antidepressants included were more likely to work than placebo.
• For most antidepressants, people were equally likely to stop taking the antidepressant as the placebo.

Question 23

NICE: psychological intervention for relapse prevention

Answer 23

People with depression who are considered to be at significant risk of relapse or who have residual symptoms, should be offered one of the following psychological interventions:

Individual CBT:
- for people who have relapsed despite antidepressant medication - for people with a significant history of depression and residual symptoms despite treatment.

Mindfulness-based cognitive therapy:
- for people who are currently well but have experienced three or more previous episodes of depression.

Question 24

Mindfulness-Based Cognitive Therapy

Answer 24

• Paying attention in a particular way: on purpose, in the present moment and non-judgementally.
• Recognising thoughts as thoughts – not ‘you’ and not ‘reality’.
• There is accumulating evidence indicating that cortisol levels decrease following participation in a mindfulness program
• recognise the thoughts, I am having the thought rather than this is happening

Question 25

Acceptance and Commitment Therapy (ACT)

Answer 25

• acceptance of thoughts rather than challenging the thoughts
• making the commitment that I will make sensible changes in my life, I’m going to do something
• a form of counseling and a branch of clinical behavior analysis.
• It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility.

Question 26

Vicious cycles of pain

Answer 26

• more low level activities can present with pain

- see slide 36

Question 27

ACT and chronic pain

Answer 27

Psychological inflexibility:
- fear of future heath and finances; loss of past health and funcition

Psychological flexibility:

Question 28

Evidence for CBT and ACT

Answer 28

The most recent systematic reviews suggest that:

• CBT for chronic pain can have positive effects on factors such as disability, negative mood and pain self-efficacy when compared with treatment as usual/waiting list, with some evidence that it is maintained at six months post intervention.
• ACT is efficacious particularly for enhancing general, mostly physical functioning, and for decreasing distress, in comparison to inactive treatment comparisons