Block 33 Week 1 Flashcards
Anxiety and Depression
1
Q
performance vs arousal curve
A
2
Q
physical symptoms of anxiety - muscle tension?
A
headaches, pain, fatigue
3
Q
physical Sx of anxiety - hyperventilation?
A
dizziness, tingling fingers + toes (¯pCO2 ® Ca2+ changes)
4
Q
physical symptoms of anxiety - sympathetic overactivity?
A
(HR +BP, ectopic beats, sweating, pale skin (cf shock), dry mouth, ‘butterflies’, nausea, loose motions, frequent urination)
5
Q
psychological symptoms of anxiety?
A
- CNS: poor conc., memory, feeling unreal
- Mood: fear, panic, worry, on edge, irritable
6
Q
thoughts in anxiety?
A
- future danger: “something bad will happen and I won’t be able to cope” (v. depression: past loss)
- Fear of dying/losing control
- Worry about worry: I will go mad/die just by worrying
7
Q
Anxiety: unhelpful behaviours?
A
- attempts at coping: (caffeine, smoking, alcohol, illegal or prescribed drugs)
- avoiding fear provoking situations
- safety behaviours
- asking for reassurance (visiting GP, somatic complaints, checking body)
8
Q
prevalence of anxiety disorders?
A
- anxiety disorders affect at least 1 in 10 ppl
9
Q
Anxiety screening tool?
A
- GAD-2
- anxiety disorder is likely if a person answers 2 or 3 to one or both Qs (ie anxiety present > 50% time)
10
Q
History taking for anxiety?
A
- triggers and situations
- thoughts - worst fears
- emotions
- physical reactions
- behaviours - before/ during/ after
- coping - avoiding, substance use, safety seeking behaviours
11
Q
free floating anxiety classifications?
A
- If free floating, present from time to time (panic) or all the time (generalised anxiety)
12
Q
anxiety: the worry tree
A
13
Q
investigations for anxiety?
A
- TFTs - hypothyroidism
- MCV/GGT - alcohol misuse
- glucose - hypoglycaemia
14
Q
other investigations that can be done for anxiety?
A
- urine - illicit drug use
- ECGs (SVT/ MVP)
- MRI head (SOL)
- EEG (TEL)
15
Q
psychological Ix for anxiety?
A
- GAD-7 for anxiety
- PHQ-9 for depression
16
Q
Tx fir anxiety?
A
- education
- relaxation
- advice on sleep and exercise
17
Q
what is CBT?
A
- psychological treatment that teaches us how to feel better by changing the way we feel think and behave = change behaviour (eg graded exposure) and/ or change thinking (eg anxiety is unpleasant but not dangerous)
18
Q
Pharmacological Tx of anxiety (3)
A
- SSRI antidepressants eg sertraline, citalopram
- Benzodiazepines eg diazepam (max 2-4wks)
- Beta-blockers eg propranolol
19
Q
what is a phobia?
A
- A marked and persistent fear
- Triggered by a specific object/situation
- Leads to avoidance of that situation
20
Q
agoraphobia?
A
(public places, crowds, shops) 6% 1 yr prevalence in population
21
Q
social phobia?
A
(eating, speaking, performing) 4%
22
Q
specific phobias?
A
(animals, heights, needles) 9%
23
Q
maintenance of a phobia?
A
- phobic stimulus -> anxiety -> avoidance -> anxiety reduced
24
Q
Tx of phobias - graded exposure?
A
graded exposure (systematic desensitisation) = the deliberate confrontation of a feared object or situation until the anxiety evoked reduces (habituates)
25
Graded exposure needs to be:
* clearly planned - SMART targets
* prolonged
* repeated freq
* graded e.g. ladder or steps
* w/o dissociation
26
how can graded exposure be done?
* Done in CBT session, then as homework
* Self-directed, or accompanied by therapist, friend or relative
* In reality or imagination (eg PTSD/trauma)
27
graded exposure can be gradual or?
one-off prolonged (‘flooding’)
28
what is systematic desensitisation?
graded exposure plus relaxation
29
CBT for generalised exposure - behavioural?
* behavioural: anx management
30
CBT for generalised exposure - cognitive?
* cognitive: tackle worry about worry
* Test out unhelpful beliefs about worry eg ‘worry helps me solve problems’
31
CBT for generalised exposure - mindfulness?
* Mindfulness: awareness plus acceptance
32
mindfulness -
* Purposeful and non-judgemental attentiveness to one’s own experience, thoughts and feelings
* letting it be
* focusing on present moment > distressing thoughts
* notice
33
CBT for panic: summary
* Education: anxiety is normal, fight or flight
* Draw a vicious circle (diagram with arrows)
* Exposure to own body sensation
* Experiments: test out fears to disprove them
34
Clark's CBT model for panic attacks?
* The trigger can be external (eg crowds) or internal (eg heartbeat) – ‘selective attention’/ ‘hypervigilence’
* The person misinterprets normal body sensations as meaning that a physical or mental disaster is imminent – ‘catastrophic misinterpretation’
* The ‘fight or flight’ survival response produces more symptoms - which fuel the ‘vicious cycle’ of panic
* attempts by the person to manage panic bring short term relief but make it worse in the long term (avoidance + safety behaviours)
35
panic diaries include?
* situation
* worst symptoms
* worst dears
* safety behaviours
* alt explanation
* behavioural experiment - nexttime it occurs
* predictons
* outcome
36
what are anxiety disorders?
* excessive anxiety - exaggeration of the normal anxiety response
* out of proportion to stimulus
* anxiety is prolonged after stimulus removed and does not assist in dealing w the situation
37
Classification of anxiety disorders?
* GAD
* Panic disorder
* Phobic anxiety disorders: social phobia, simple phobia, agoraphobia
38
GAD =
* anx symptoms persistent but may fluctuate in intensity, not situation specific
39
GAD symptoms?
* sleep disturbance
* worrying
* feeling on edge
* irritability
* poor conc
* autonomic symptoms - palpations, sweating, dry mouth
* inc muscular tension giving rise to head, neck and backaches
40
epidemiology of GAD?
* 1 year prev - 3%
* F >M
41
DDs for GAD
42
RF for GAD?
* Genetic
* biological mechanisms - breakdown of the mechanisms
* personality traits - neuroticism
* childhood adversity - especially when lack of secure attachments
* stressful life events
43
Panic disorder?
* panic attacks often occur w other disorders e.g. GAD, agarophobia, depressive disorders
* the anxiety is unrelated to any paticular circumstances so is unpredictable
44
what are panic attacks?
* characterised by sudden onset of symptoms, reaching a peak within 10 mins
45
panic attacks - depersonalisation vs derealisation?
* depersonalisation = patient feels detached from their surroundings, feel unable to feel emotions - out of body experiences
* derealisation = surrounds don't seem real
46
symptoms of a panic attack?
* sweating, hot flushes
* SOB
* paraesthesia
* dizziness
* choking
* chest pain, palpations
47
prevalence of panic attacks?
* 1.4% 1 year prevalence
48
phobic anxiety disorders?
* intermittent episodes of anxiety occuring in spec circumstances
* anxiety out of prop to threat
* can lead to anticipatory anxiety and habitual avoidance of the circumstances
49
Specific/ simple phobias?
* fear of spiders e.g.
* onset in childhood usually
* 1 yr prev ~4%
50
social phobias?
* fear of performance failure and negative evaluation in social situations
* onset in teenage years usually
* 1 yr prev 7% which reduces in adults
51
agoraphobias?
* symptoms provoked by being away from home, in situations which can't be left easily such as crowded or confined spaces e.g. supermarkets, cinemas
* in severe cases ppt may be housebound
52
agoraphobias - onset is usually before?
35
53
agoraphobia - 1 yr prev is double in?
females
54
aetiology of agoraphobia?
* ppts often constitutionally vulnerable to anxiety symptoms which they may exp and misinterpret in certain situations
* conditioning and avoidance maintain the symptoms as can the response of family members
55
RF for agoraphobias?
* Genetics
* personality traits e.g. dependent personality traits
* learning theories - conditioning and avoidance
* family influences e.g. overprotective
56
OCD prevalence?
* 1 yr prev = 2%
* F =M
57
OCD - mechanism?
* Obsession can be a thought, impulse or action
* there is a sense of complusion associated with it
* it is resisted leading to anxiety
* it's recognised as nonsensical and is recognised as coming from within the patient
58
Types of obsessional phenomena - thoughts and impulses?
* thoughts - e.g. single words, usually unpleasant
* impulses - or urges to perform violent or embarassing acts
59
types of obsessional phenomena - ruminations and rituals?
* ruminations - endless internal debates abt trivial problems
* rituals - counting or cleaning, checking
60
brain disorders linked to OCD?
encephalitis lethargica, Gille de la Tourette syndrome
61
PTSD?
* severe reaction to extremely stressful circumstances
62
core features of PTSD?
* hyper-arousal
* re-experiencing aspects of the stress e.g. flashbacks, dreams, thoughts
* avoidance of reminders
63
What are adjustment disorders?
* reaction to stressful experience which is understandanle and in prop e.g. divorce
* symptoms can be v variable but can include many anxiety symptoms
* worries usually focused on the stressor
64
Mixed anxiety and depressive disorder ?
* symptoms of both equally present
* neither dominates
* neither symptoms severe enough to meet criteria for an anxiety or a depressive disorder
65
Tx of anxiety?
* psychological treatments are the treatment of choice
* include counselling, CBT
66
specific psychological technique for phobias?
exposure therapy
67
spec technique for obsessional phenomena?
thought stopping
68
pharmacological management of anxiety?
* antidepressants - anxiolytic affects used for GAD and panic attacks
* BBs useful for palpations and tremor from anxiety
69
precipitating factors in GAD?
Stressful life events eg relationship problems, physical illness, threatened loss of employment (contrast losses - which tend to provoke depression)
70
Maintaining factors in GAD?
- CBT theory states that in GAD worrying abour worry maintains anxiety and leads to unsuccessful attempts to control it
71
mechanism of phobias - natural selection?
* phobias are acquired not innate
* Evolutionary theory suggests that increased likelihood of fear towards certain objects (snakes, spiders, being alone, the dark) conferred a survival advantage to our ancestors, leading to natural selection
72
the double learning theory suggests a 2 stage acquisition of fears:
1 - pavlovian conditioning
2 - maintained by operant conditioning
73
pavlovian conditioning?
- initial acquisition of a phobia
- (association of a conditioned with unconditioned response) eg lost and anxious when out walking as a child and see a cat leading to cat phobia
74
operant conditoning?
- maintains the phobia
- Contact with cats causes anxiety (punishment) leading to less contact, plus avoidance of all cats brings reward of no anxiety (= negative reinforcement).
75
step 1 of the CBT model of panic disorders?
- catastrophic misinterpretation of body systems
- panic occurs and is maintained by an inappropriately learned response to normal physiological symptoms (eg palpitations)
76
step 2 in the CBT model of panic disorders?
Selective attention to body symptoms and avoidance of anxiety provoking situations also reinforces behaviour.
77
OCD presentation in males?
* earlier onset
* clinical themes: exactness, sexual, odd rituals, symmetry
* asosicated with increased rates of bipolar disorder
78
OCD presentation in females?
* later onset
* more aggressive obsessions and cleaning compulsions
* associated with increased rates of panic disorder
79
biochemistry behind OCD
80
psychodynamic theory of OCD - Freud?
* OCD represents defensive regression to anal stage
* (defensive triad of orderliness, obstinacy and parsimony ie stinginess).
- utilisation of defence mechanisms
81
defence mechanisms in OCD - reaction formation?
* Reaction formation = feeling or behaving in a way which is opposite of unconscious unacceptable impulses (eg excessive prudery if increased sex drive)
82
defence mechanisms in OCD - undoing?
attempting to cause past thoughts not to have occurred
83
defence mechanisms in OCD - isolation?
separation of an idea from its associated affect
84
precipitating factors in OCD?
environmental stress especially life events indicating increased responsibility
85
maintaining factors of OCD - behavioural theory?
* rituals (checking, cleaning etc),
* avoidance and reassurance seeking produce short-term relief from anxiety symptoms but cause long-term worsening of problems (negative reinforcement of behaviour, operant conditioning)
86
maintenance of OCD - cognitive theory?
* states that OCD kept going by exaggerated appraisal of threat, assuming excessive responsibility for consequences, and attempts to suppress recurrent worrying thoughts
87
Managament of OCD?
* Offer info, education, self help and support groups
* involve family/carers (drop reassurance/safety seeking), involve religious or community leaders (if OCD/culture boundary unclear)
- involves a stepped care model
88
secondary/ specialist care for OCD?
* only gets involved if comorbitidy. severe or treatment resistant cases
89
mild OCD (functional impairment)?
CBT (under 10 therapist hrs) using individual, phone, structured self help or group approach
90
moderate OCD Tx?
1) Offer either any SSRI or CBT (over 10 therapist hrs): both equally effective
2) Increase dose after 4-6 weeks if no response
91
moderate OCD - review for?
- 12 months and then discharge back to PC if well
- Teach individual to adapt techniques learned to new symptoms
92
severe OCD first line?
1) Offer SSRI and CBT in combination
93
severe OCD - if no response after 12 weeks offer?
2) No response after 12 wks (or patient not engaged): different SSRI, and then/or
3) Clomipramine up to BNF max (+ECG+BP if significant CVS disease)
94
step 4 in the management of severe OCD?
Refer to “Specialist multidisciplinary team with expertise in OCD/BDD” whose roles are to: advise, assess, treat, educate + increase skills of other professionals
95
OCD in children and younger ppl?
* more emphasis on age approproate family, indiv and group interventions
* recommends CBT first line 12 weeks for all OCD even if severe
* then consider adding SSRI
96
body dysmorphic disorder Tx pathway?
* same as OCD (CBT/SSRI, stepped care, specialist teams) but
* fluoxetine is the first choice drug 1)
* then other SSRIs then try adding in buspirone.
97
Acute stress reaction includes?
* Includes crisis reaction
* e.g.s accident, battle, criminal assult, domestic fire
* onset - immediate or within minutes vs within 6 months for PTSD usually
98
duration of acute stress reactions?
* duration 0-72 hrs, PTSD is over 1 month - lifelong
99
symptom clusters in PTSD?
Traumatic event + the RAHR symptom clusters
100
RAH + Reaction mneumonic?
- Re-experiencing
- Avoidance
- Hyperarousal
- Reaction - altered cognitions and mood
101
PTSD - re-experiencing?
* thoughts, dreams, flashbacks
* dissociative reactions - derealisation, depersonalisation, losing conciousness
* distress or reactivity when exposed to traumatic reminders
102
PTSD - avoidance?
* of thoughts, feelings, people, places, conversations, activities, objects or situations associated with the trauma or that evoke memories of it
103
PTSD - hyperarousal?
* Irritable, aggressive, self destructive or reckless behaviour
* Hypervigilance (scanning for danger)
* Exaggerated startle response (eg jumps to loud noise)
* Sleep disturbance. Difficulty concentrating.
104
PTSD - reaction?
- altered cognitions and mood
- began/ worse after trauma
- negative emotions and beliefs
105
PTSD - reaction: dissociation
Inability to recall an important aspect of the trauma (amnesia)
106
PTSD reaction - diminished...
interest/participation in normal activities
107
For PTSD diagnosis, symptoms need to be present for?
one month and clinically sig distress or functional impairment
108
complex PTSD?
* An event or series of events of an extremely prolonged or repetitive nature, most commonly where escape is difficult or impossible
* Symptoms of PTSD - RAHR plus BAR
109
BAR mneumonic for complex PTSD?
Beliefs - persistent beliefs as self as dimished, defeated or worthless
Affect - problems in affect regulation
Relationships - difficulties in sustaining relationships
110
PTSD aetiology - predisposing factors?
pre-morbid personality
111
PTSD aetiology - precepitiating?
stressor event
112
PTSD aetiology - maintaining?
victim's enviornment
113
pre-morbid personality in PTSD?
* genetics
* personality
* childhood abuse, adult trauma, drug and alcohol abuse
* neurotic disorder
114
what happens in PTSD?
* Extreme, prolonged or repeated stress -> overactivity of normal defence mechanisms, involving 3 catacholamine systems
115
PTSD - NA system?
locus coeruleus/noradrenaline system -> activity of amygdala, hippocampus, hypothalamus and cerebral cortex
116
PTSD - dopamine system?
prefrontal cortex activity
117
PTSD - sensory nervous system?
physiological arousal + NA + A secretion
118
therapies treating PTSD?
- CBT
- psychoeducation
- EDMR
119
Psychoeducation for PTSD?
- Psychoeducation about reactions to trauma, strategies for managing arousal and flashbacks
- processing trauma related memories
- overcoming avoudance
- improving function (work/ social relationships)
120
EDMR?
* eye movement desensitisation reprocessing
- should use repeated in- session bilateral stimulation for specific target memories (often visual images) until memories no longer distressing, plus teaching of self-calming/techniques to manage flashbacks within and between sessions,
121
drug therapies for PTSD?
- not first line, usually added onto CBT/ EMDR
* venlafaxine or any SSRI e.g. sertraline or paroxetine
122
which drugs can be added to antidepressants to manage hyperarousal?
* antipsychotics like risperidone can be added for disabling symptoms like hyperarousal, or if not responding to other symptoms
123
exposure therapy for PTSD?
* Role of therapist in exposure work = to encourage patient to describe trauma as if they were in the situation now
* Therapist first presents rationale for exposure
* ppt rates fear/distress at the beginning, middle and end
124
exposure therapy - rewind and hold technique?
* rewind and hold technique - encourage ppt to stop and go back over the hot stop to allow habitation to occur
125
Cognitive therapy aims to change the way people feel by:
a) challenging their automatic negative thoughts and underlying assumptions eg using a diary of situation, thoughts, evidence for/against thought being true
b) getting patient to suggest more rational ,alternative, balanced explanations.
126
dissociative disorder (hysteria)?
* production of symptoms and signs of illness in absence of physical pathology
* involuntary
* not automatic
* usually involves signs of CNS
127
hysteria epidemiology?
* F>M 6:1
* commoner in developing countries
* usually presents before 40
128
main features of hysteria?
- partial or complete loss of normal integration between memories of the past, awareness of identity + immediate sensations + bodily movements
129
dissociative states =
traditionally mental symptoms + signs in absence of organic brain disease.
130
what can be seen in hysteria?
* Narrowing of field of consciousness (restricted awareness) which may be limited to one area of experience eg amnesia, stupor, fugue, trance, Ganser’s syndrome, multiple personality
131
coversion disorder?
* Conversion disorder = traditionally physical symptoms + signs occurring in organs under voluntary (not autonomic) control (usually nervous system)
* eg paralysis, weakness, bizarre gait, abnormal movements, dysphonia, blindness, pseudoseizures, numbness.
132
RF for anxiety?
* Female sex
* Family history
* Childhood abuse and neglect
* Environmental stress (e.g. redundancy, divorce)
* Emotional trauma
* Substance abuse
133
diagnostic criteria for anxiety?
134
step 1 of anxiety management?
* address environmental stressors and substance abuse issues
* assess severity, duration and impact on normal life
* evaluate for co-existing depression
135
step 2 of anxiety management?
* low intensity psychological interventions
* includes individual non-facilitated self-help, individual guided self-help and psychoeducational groups.
136
Step 3 - GAD with marked functional impairment or that has not improved after step 2 interventions?
* high intensity psych intervention
* pharmacological treatment - SSRI or SNRI (ventafaxine)
137
step 4 of anxiety management?
* referral to specialist care
* if steps 1-3 didn't work
* or if risk of SH/ suicide, significant co-morbitiries or self neglect
138
interaction between cognitive, behavioural, emotional and physiological factors in anxiety?
* thoughts affect behaviour, emotions and physiological state
* behaviours affect thoughts, emotions and physiological state
- CBT addresses these domains
139
CBT - challening the cognitive domain of anxiety?
* Identifying and re-evaluating negative thoughts, beliefs and patterns of thinking
* Learning more effective problem-solving and decision-making strategies
140
CBT - cognitive - mindfulness?
* Using mindfulness to deal with “uncontrollable” and racing thoughts, allowing you to let go of unnecessary thoughts without getting caught up in them
141
CBT - challenging the behavioural domain of anxiety?
* Changing unhelpful behaviours such as social isolation, avoiding situations, procrastination and inactivity
* Learning to be more assertive and communicate more effectively
* Pursuing pleasurable activities and interests that promote happiness and make life more meaningful and fulfilling
142
CBT - challenging emotional domain of anxiety?
* Learning how to experience and accept negative emotions without becoming overwhelmed
* Techniques to transform painful emotions into more manageable feelings
* Strategies to help tolerate emotional distress and manage extreme emotional reactions such as intense anger, anxiety or sadness
143
CBT - challenging physiological domain of anxiety?
* Breathing exercises and relaxation techniques to calm physiological responses and reduce stress levels
* Mindfulness practices to cope with stress and physical discomfort or pain
* Improving sleep, diet and exercise habits to improve physical well-being
144
Stress response in anxiety?
* activation of SNS
* body's fight or flight response activates -> adrenaline, NA and ACTH release
* allows us to peform well in a short term situation
145
personality and anxiety?
* individuals with high neuroticism scores were more likely to feel anxious
* correlation between anxiety, introversion and neuroticism
146
coping strategies in anxiety?
* limiting alcohol and caffiene
* sleeping well
* deep breathing
* exercising and setting small daily goals
* distracting yourself - e.g. music, books, podcasts
147
resilience factors =
* Resilience factors (RFs) are psychological resources that buffer the potentially negative effects of stress on mental health.
148
examples of resilience factors?
* the ways in which individuals view and engage with the world
* the availability and quality of social resources
* specific coping strategies
149
problem solving and anxiety?
* anxiety (especially chronic) can hinder our ability to filter things that we think of as a threat in order for our brains to accurately concentrate on the retrieval of info necessary for problem solving
150
members of community MH teams?
* nurses
* occupational therapists
* psychologists
* MH support workers
* consultant psychiatrists
151
Community mental health teams work as part of an MDT to:
* provide medical support
* putting patients in touch with other agencies
* short term work for a specific mental health diagnosis which requires short term support
* physical health monitoring
152
CMHTs work as part of an MDT and can provide support with (3)?
* support w employment support
* psychological approaches
* support with day to day activities and functioning
153
organisiation of MH services?
* Primary care - GP
* community - MH teams
* hospitals and in specialist services
* this is primary, secondary and tertiary care
154
NHS LTP?
is going to create intergrated community mental health servcies
155
primary MH services?
GP - refer to secondary services but these can also be accessed through the single point of access
156
secondary MH services?
specialised, include teams like community MH teams, crisis resolution and home treatment teams and hospital care
157
voluntary MH services?
- Running alongside primary and secondary services are voluntary services: support provided in the community, usually by charities and other non-profits.
- You can often access these services without a referral
158
tertiary MH services?
highly specialised treatment like forensic MH services or specialist psychotherapy services
159
intergrated care systems =
* removing traditional divisions between different tiers of care
* so that people get less disjointed care
160
what do ICS aim to do?
* aims to remove divisions such as those between hospials and GPs, physical and mental health and the NHS & local authority
161
ICS are new partnerships between?
between the NHS and other health and care organisations. Such as the local authority, voluntary sector and social enterprise sector
162
depression epidemiology?
* 4th leading casue of disability worldwide
* point prevalence 2-5%
163
one depressive episode =
F32 Depressive Episode
164
if there is more than one depressive episode it's either:
* F31 Bipolar Affective Disorder
* F33 Recurrent (Unipolar) Depressive Disorder
165
RF for depression?
- genetics
- Gender – twice as common in women
- Childhood experience – e.g. loss of parent, lack of parental care, abuse
- Personality – especially neuroticism
- Social environment – life stresses, lack of social network etc
- Physical illness
166
ICD-10 criteria for depression
167
Tx of depression - non pharm?
* Education
* Lifestyle changes - diet, alcohol, sleep hygiene
* Physical health problems improved
* Problem- solving - helping resolve trigger factors like unemployment or marital problems
168
Psychological treatment (psychotherapy) for depression?
* attempt at relieving a person's psychological distress using psychological means
* different methods of counselling - CBT, CAT, psychodynamic
169
what does psychotherapy involve?
* Confiding relationship for listening and talking
* Release of emotion
* Giving information
* Provision of rationale to make problems understandable
* Restoration of morale
170
levels of CBT - self help materials?
* Self-help materials – This is not a form of psychotherapy and no CBT skills or training are required by the individual reading the self-help material (e.g. books/ websites).
171
levels of CBT - assisted self help?
* Assisted self-help - computerized CBT, self-help material presented to a support group or individuals by a health worker, such as a graduate mental health worker or assistant psychologist
172
levels of CBT - CBT approaches?
* CBT approaches - Specific CBT interventions for specific problem areas, e.g. anxiety management, coping with voices etc.
173
levels of CBT - formulation driven CBT?
* Formulation driven CBT– This is a form of psychotherapy, the patients are not fully able to help themselves and have sought help from a trained professional.
174
what are the levels of CBT?
1) Self help materials
2) assisted self help
3) CBT approaches
4) formulation driven CBT
175
what do the therapist and patient agree on during CBT?
* Patient and therapist agree problem list and goals. Treatment is a collaborative partnership
* Focuses on ‘here and now’
176
Which type of questioning is used in CBT?
* socratic questioning used by the therapist
* open therapeutic process
* homework used
177
what is the CBT model of depression?
* Underlying beliefs centre around being helpless or unloveable
* Trigger events typically involve loss or ‘failure’
* This produces negative cognitions about self/ future/ world which reinforce underlying beliefs, and affect mood and behaviour
178
CBT model of depression - how are negative thoughts maintained?
* These negative thoughts are maintained by distorted information processing (e.g. overgeneralization, personalization, selective abstraction)
179
techniques used in CBT?
* Activity monitoring and scheduling (mastery and pleasure)
* Distraction
* Systematic desensitization
180
techniques used in CBT - anxiety management?
progressive muscular relaxation, imagery, breathing control etc
181
cognitive techniques used in CBT?
* identifying and challenging negative thoughts using thought records -replacing with balanced thoughts
* identifying cognitive biases
* working on deeper levels of cognition like behavioural experiments to challenge dysfunctional assumptions
182
social factors in depression ?
* Social problems
* Past history of depression
* Chronic disease e.g. diabetes, heart disease, chronic obstructive pulmonary disease, cancer
* Alcoholism
* Bereavement
* Old age
183
red flags in depression?
* Risk of suicide
* Feeling of hopelessness
* Chronic pain
* Disabling symptoms
* Severe and prolonged symptoms
184
How do young adults tend to present with depression?
* Young adults tend to sleep a lot, overeat, withdraw and show self-neglect.
185
how do older adults tend to present with depression?
* Older adults often present with insomnia, anxiety, anorexia, poor self-care and exacerbation of pre-existing physical conditions like painful arthritis, constipation, head and neck and back pain
186
Diagnostic criteria for depression
187
which drugs can cause depressive symptoms?
* BBS and psychoactive medications can cause depressive symptoms
188
mania?
* mania = period of elation - high mood
* can be mild (hypomania) or severe (mania)
189
bipolar disorder =
* mania + depression = bipolar disorder/ manic depression
190
depression is the ? most common reason for consulting a GP
3RD
191
top 10 presenting symptoms of depression ?
* tiredness
* headache
* stress
* low mood
* backache
* sleep problems
* chest pains
* indigestion
* dizziness
* pain
192
Normal grief reactions?
* shock, denial, numbness, guilt, sadness, weeping, resolutuon
* Emotional and practical support is normally sufficient.
193
abnormal grief reactions?
* if symptoms are more intense e.g. clinical depression or if they're prolonged (beyond 6 months) or if they're delayed in onset
* Counselling, “guided mourning” and occasionally medication may be needed.
194
socio-cultural aspects of depression - black and asian races present less ofern with?
* Black and Asian races present less often to their GP with “depression”
* Some groups are more likely to complain of physical symptoms eg Mediterranean (“nerves, headache”), China & Asia (“weak, tired”),
195
what are risk factors for suicide?
* migration and not speaking the local language are risk factors for suicide
* refer to specific services e.g. Refugee council and use a professional translator
196
depression acronym for symptoms
197
for depression to be diagnosed there needs to be?
* 4+ symptoms for at least 2 weeks include at least 2 of the first 3 core symptoms
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how can severe depression present?
* severe depression can present with psychotic symptoms e.g. delusions or hallucinations
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somatic syndrome?
Depression may be more significant and respond to antidepressants if somatic (“biological”) symptoms* are present: sleep/app/wt change, anhedonia, loss of libido, constipation, amenorrhoea
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mild depression =
* 4 symptoms
* distressed but able to continue functioning
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moderate depression =
* 5/6 symptoms
* great difficulty continuing w normal functioning
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severe depression =
* 7 to 10 symptoms
* totally unable to work or function
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MSE considers?
* Appearance
* behaviour
* speech
* thoughts
* perceptiuon
* mood
* cognition
* insight
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drugs linked to depression?
* Drugs: steroids, contraceptive pill, digoxin, beta blockers
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causes of depression - illness?
* Any physical illness eg hypothyroidism, heart disease, stroke, cancer, MS
* Other mental disorders eg psychosis, dementia, alcohol excess, illicit drug abuse
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depression is linked to?
* linked to reduced levels of serotonin and noradrenaline
* Some bipolar patients have enlarged cerebral ventricles on CT scan
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depression is an independent RF for?
* Depression is an independent risk factor for osteoporosis (10% drop in bone density) & coronary heart disease (2-4 times increase in angina, MI & sudden death)
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Bipolar I disorder =
dep plus mania.
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bipolar II disorder =
dep plus hypomania
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clinical features of bipolar?
* elated or irritable mood
* high energy/ libido
* reduced sleep and appetite
* rash behaviour and debts are risks
* grandiose, paranoid delusions
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advice for a bipolar patient?
* avoiding alcohol and drugs
* no over stimulation
* ensure sleep and regular routine
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physical tx for bipolar - depression?
* Antidepressants eg SSRIs
* Anti-psychotics (if psychotic)
* Lithium (if treatment resistant),
* ECT (if life threatening)
mania
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physical treatments for bipolar - mania?
* Antipsychotics eg olanzapine+/-mood stabilisers eg lithium
* ECT (if treatment resistant)
* Lorazepam (if aggressive)
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adjustment disorder =
if depressive symptoms present than less than2 weeks - milder short period of low mood due to stressful life events
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mild to moderate depression Tx?
- low intensity psychosocial interventions
- guided self help based on CBT princuples, behavioural activation and problem solving techniques
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moderate to severe depression Tx?
- antidepressants and CBT or interpersonal therapy
- high intensity psychological interventions - 16-20 sessions over 3-4 months
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severe/ complex depression Tx?
Crisis or home treatment teams, inpatient admission, ECT
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recurrent depression Tx?
individual CBT, or mindfulness (if now well but 3 or more episodes = group mindfulness-based CBT)
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drugs for the different depression severities?
* mild: not unless prolonged
* moderate to severe: drugs and therapy
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drug pathway for depression?
1. SSRIs
2. other SSRI or mirtazepine or lofepramine,
3. Venlafaxine / TCA/ MAOI
4. Add lithium / antipsychotic eg quetiapine / mirtazapine
5. ECT
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psych treatments work best in which type of depression?
mild to moderate
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physical treatments work best in ? depression
* Physical treatments (drugs & ECT) work best in moderate to severe depression.
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the stepped approach in depression?
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all psychotherapies involve:
* A therapeutic conversation ie talking = exchange of information + instillation of hope
* A therapeutic relationship (alliance) between therapist and ‘client’/patient
* A therapeutic rationale ie an explanation followed’ by therapist & patient
* A therapeutic base ie regular meetings in time & place (eg 1 hour every week)
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ECT is used for?
* used for severe/ life threatening depression requiring a rapid response (not eating or drinking, acutely suicidal, retarded, psychotic) or if other treatments are ineffective
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ECT increases synthesis of?
* ECT involves giving a short acting IV general anaesthetic plus a muscle relaxant.
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what happens in ECT?
* A pulsed electric current is then passed through the brain to produce a brief (15-60sec) grand mal seizure. Patients vary, but often need 6 to 12 sessions, given twice weekly
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Circle of depression and inactivity
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bipolar 1 vs bipolar 2?
Bipolar I disorder often leads to problems with day-to-day life and hospital admissions, whereas in bipolar II disorder there are no psychotic features and less impact on function.
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hypomania?
* In hypomania, there is increased energy and activity with persistently elevated mood, which occurs without delusion or hallucinations.
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patterns in bipolar can be negatively influenced by?
* patterns of cycles in bipolar disorder can be negatively influenced by drinking, stress, ilict drugs and other medical conditions
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PMH - which conditions can cause symptoms of mania?
* PMH - HIV infection, syphilis, thyroid disease and epilepsy), which can may cause symptoms of mania through their effects on the brain.
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first line medications in mania?
AP
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meds for mania?
- antipsychotics
- medium to longer term: mood stabilisers
- antidepressants and benzodiazepines
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mood stabilisers in mania?
valproate and lithium
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AD in mania?
should usually be stopped during the manic phases
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benzodiazepines in mania?
short term use, sometimes used for severe agitation
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systemic steroids can result in?
secondary mania or depression.
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speech in mania?
* Speech. Pressure of speech will usually be obvious during manic phase. Slowed speech is characteristic of the depressive phase.
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thoughts in mania?
* Thoughts. Thoughts may be racing and flight of ideas will be present.
* Grandiose ideas may come up during the review.
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energy in mania?
* Energy. The person will usually appear very energetic and hyperactivity is common.
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eye contact in bipolar?
* Eye contact. In the depressive phase, eye contact may be reduced.
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affect in bipolar?
* Affect. Patients may be tearful and apathetic during the depressive phase.
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ECT - discussions?
* valid informed consent needed
* right to withdraw at any time
* carers/ advocates should be involeved to facilitate informed discussions
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ECT - if informed consent not possible?
* if informed consent is not possible, ECT should only be given if it does not conflict with a valid advance decision, and the person's advocate or carer should be consulted.
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ECT - monitoring?
* assess clinical status after each ECT treatment and stop treatment when remission has been achieved or sooner if side effects outweight the potential benefits
* Assess cognitive function before the first ECT treatment and monitor at least every three to four treatments, and at the end of a course of treatment.
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ECT monitoring - addenbrooke's cognitive assessment?
* addenbrooke's cognitive assessment mainly used - measures new learning, retrograde amnesia and subjective memory impairment
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advantages of ECT?
* Effective when other treatments don’t work
* Most effective with most severe illness
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Disadvantages of ECT?
* Multiple brief anaesthetics
* Acute confusional states
* Memory impairment: anterograde and retrograde
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Meds that interfere with ECT?
anticonvulsants and lithium
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short term ECT side effects?
* headache
* muscle aches
* distressed
* tearful
* frightened
* temporary memory loss
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ECT - damage to?
* damage to tongue, teeth or lips because ECT causes contraction of the jaw muscles
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LT ECG side effects
* memory problems
* personality change
* lost skills
* 'feel like a different person;
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