CASC Stations 4 Flashcards
Types of indecent exposure?
Exhibitions - sudden powerful urge with little attempt to avoid capture and no further attempt to contact victim
Disinhibited - alcohol, drugs, stress, dementia, hypomania
Aggressive, impulsive and antisocial
Reoffending rate of indecent exposure
20-30%
Predictors of sexual reoffending
• Male Gender
• Low IQ
• Lower Age
• Previous criminal record/Previous history of sexual offence
• History of child hood sexual abuse, and other abuse
• Juvenile sex offences
• Deviant sexual practices like excessive masturbation, self
reported deviant sexual fantasias and urges.
• Involved in Paraphilia (Exhibitionism, Voyeurism)
• Previous history of poor engagement with services
• Personality disorder (esp. antisocial PD)
• Access to victims, Attitudes towards victim - low victim
empathy, justification of sexual crimes, and that they’re
entitled to express their high sexual drive
• Intoxication with drugs/ alcohol
Characteristics of high deviancy paedophiles
- They committed offences outside and inside the family
- They offended against both boys and girls
- They were twice as likely to have committed previous sexual
offences - They were more likely to have been abused as a child.
Paedophile assessment construct
Assess circumstances of the act/offence, Intent of
the act, Grooming activity
Obtain Patients’ view about the offence and arrest;
Denial, minimisation, justification, lack of remorse,
lack of guilt, low victim empathy, feelings of
‘entitlement’
Obtain relevant Personal history (traumatic
childhood, history of childhood abuse), Past
psychiatric history, Drug and alcohol history
Obtain relevant Psycho-sexual history (deviant
sexual practices, excessive masturbation and urges,
sexual fantasies, Paraphilia, h/o paedophile
activity, sexual preference - attracted to children,
explore sexual activity & relationship with adults
Previous Forensic history (sexual and non-sexual
offences), juvenile sexual offences, history of
cautioning, conviction, sentencing, previous history
of similar offences)
Assess Current social circumstances- friends and
support system
(Unemployment, homelessness, lack of stable
Relationships, abnormal personality traits-
impulsivity, lack of empathy)
What is fitness to stand trial?
Ability to conduct oneself appropriately in court
Sx of anorexia
• Weight loss > 15% and below expected BMI (Body mass
index) of 17.5 or less
• Body image distortion-Fear of fatness held as an intrusive
overvalued idea
• Avoidance of fattening foods, with behaviours aimed at
losing weight like vomiting, purging, over exercise, use of
appetite suppressants and/or diuretics.
• Amenorrhoea in women, a loss of sexual interest and
potency in men
• Pubertal delay if onset is early
Sx of bulimia
• Persistent preoccupation with food & eating and an irresistible
craving for food
• Binges-episodes of overeating
• Attempts to counteract the ‘fattening’ effects of foods by one or
more of the following like self-induced vomiting, alternating
periods of starvation, purgative abuse, over exercise and use of
appetite suppressants, diuretics
• Morbid fear of fatness with imposed ‘low weight threshold’
Physical health questions in eating disorders
a. Menstrual changes
When was your last period? Are you menstruating regularly?
b. Changes in libido
c. Symptoms of anemia: weakness, lethargy, constipation
Do you feel the cold badly?
Have you noticed any weakness in your muscles?
Have you fainted or had dizzy spells?
Predictors of poor prognosis in eating disorders
- Old age at illness onset
- Life time history of anorexia
- Poor impulse control
- Pre-morbid obesity
- Poor social adjustment
- Substance misuse
- Co-morbid affective disorder
- Low self esteem
Risk factors for poor outcome in anorexia
• Male sex
• Late onset
• Longer duration of disorder before presentation
• Chronic course of illness
• Excessive weight loss
• Longer duration of amenorrhoea
• Bulimic features (more bingeing behaviors, Vomiting and
purging as part of the clinical picture)
• Poor social adjustment
• Poor parental relation ships, Greater family hostility
• Psychiatric co-morbidity especially cluster C personality
disorders, depression, OCD, substance misuse and autistic
spectrum disorders
• Anxiety when eating with others
What does OP treatment of eating disorder involve
Outpatient management should involve a psychological treatment
with physical monitoring provided by a healthcare professional
competent to give it and to assess the physical risk of the illness to
the patient, and the monitoring should normally continue for at least
6 months
Goals of IP treatment in eating disorders
• Addressing physical and psychiatric complications
• Development of a healthy meal plan
• Addressing underlying conflicts, such as low self-esteem and
planning new coping strategies
• Enhancing communication skills§
• Hospitalise for weight restoration and monitoring as part of
the medical management. It is reasonable to aim for a weight
gain of between 0.5 and 1 kg each week, & weight restoration
takes between 8 and 12 weeks
• Rehydration and correction of serum electrolytes.
• Instigate nutritional rehabilitation and involve the dietician for
nutritional counselling: Aim for a target weight, refeeding
programme- a balanced diet of 2500 – 3000 k calories/day
provided as three or four meals a day with supplementary
snacks.
• Following weight restoration, the patient should be offered
outpatient psychological treatment, and typically this
outpatient treatment and physical monitoring following
inpatient weight restoration should continue for at least 12
months
• Offer support at meal times, monitor her food intake
• Eating pattern should be supervised by a nurse to provide
support, reassurance and to ensure that the patient does not
induce vomiting (or) take purgatives.
• Monitor for Suicidality, impulsive behaviour
Psychological treatment of eating disorder
Psychoeducation CBT IPT Focal psychodynamic Family interventions in CAMHS (NICE)
CBT in ED
The psychologist would attempt cognitive restructuring to
identify automatic negative thoughts and to challenge core beliefs.
CBT has been particularly used with the aim of modifying
abnormal cognitions about shape, weight and eating and the
behavioural component focuses on behavioural experiments
include self-monitoring of weight, goal setting, assertiveness
training and relaxation.
Outcome of Anorexia
Ø More than half of sufferers make a recovery.
Ø The average duration of illness is between 5 or 6 years
Ø Sometimes it may take a long time like 15-20 years for people
to make complete recovery
Ø 1 in 5 of severely ill people may also die
Treatment of bulimia
Diary of eating habits and developing self control
Dietary counselling and education
High dose fluoxetine can reduce urge to eat
Psychotherapy
Family interventions in CAMHS (NICE)
CBT
IPT
Outcome of bulimia
Ø More than half of sufferers recover and would cut their
bingeing and purging by atleast half, will help people to get
back some control of their life
Ø Recovery usually takes place slowly over a few months or in
cases over many years
Ø Both CBT and IPT work just as effectively over a year
Ø Research evidence suggests that Combining medications and
psychotherapy is found to be more effective than either
treatments on its own.
When is risk of refeeding highest
First 2 weeks
Usually within 4 days of refeeding
Characteristics of refeeding syndrome
- Oedema
- Excessive bloating
- Features of congestive cardiac failure
Low phosphate
What happens in refeeding
Most effects result from a sudden shift from fat to carbohydrate
metabolism and a sudden increase in insulin levels after refeeding
which leads to increased cellular uptake of phosphate.
Refeeding increases the basal metabolic rate. Intracellular movement
of electrolytes occurs along with a fall in the serum electrolytes
including phosphate, potassium, magnesium, glucose, and thiamine.
Significant risks arising from refeeding syndrome include confusion,
coma, convulsions, and death. The shifting of electrolytes and fluid
balance increases cardiac workload and heart rate. This can
lead to acute heart failure. Oxygen consumption is also
increased which strains the respiratory system and can make
weaning from ventilation more difficult.
Treatment of refeeding
Refeeding syndrome can be fatal if not recognized and
treated properly. If potassium, phosphate or magnesium are low then
this should be corrected. Prescribing thiamine, vitamin B complex
(strong) and a multivitamin and mineral is recommended.
Biochemistry should be monitored regularly until it is stable.
Monitoring for refeeding
• Measure U&Es and correct abnormalities before re-feeding.
• Recheck U&Es every 3 days for the first 7 days and then weekly
during re-feeding period.
• Attempt to increase daily caloric intake slowly by 200- 300 kcal
every 3-5 days until sustained weight gain of 1- 2 pounds per
week is achieved.
• Monitor patient regularly for development of tachycardia or
oedema.
Management of PND
Psychoeducation to patient and family Monitoring those at risk Individual/marital counselling CBT Antidepressants Prevention through enhancing coping and stress management techniques, relaxation training
Risk factors for PND
- Older Age
- Single mother
- Unplanned pregnancy
- Personal history of depression
- Family history of depression
- Poor social support
- Significant other psychosocial stressors
Risk factors for postpartum psychosis
- Personal history of major psychiatric disorder
- Previous postpartum psychosis (30% risk of developing
psychosis in the subsequent pregnancies) - Family history of major psychiatric disorder
- Single parenthood
- Lack of adequate social support
Advice for breastfeeding if on antipsychotics
• Most psychotropic medication are not indicated during
lactation period, Therefore discontinue and change it to bottle-
feeding preferably, it gives the mother some rest especially
during the acute phase of the illness.
• If the mother still decided to breastfeed, then the benefits
would have to be weighed against the risk of exposure in the
infant. In which case I would use low dose lowest optimum
dose of antipsychotics preferably Sulpiride or olanzapine
(recommended by the Maudsley guidelines 2007)
• I would tend to avoid drugs with long half life and the time
feeds as to avoid peak plasma drug levels in the milk
Good prognostic factors for postpartum psychosis
- Acute onset
- Affective illness
- Good social support.
- First episode
- Well adjusted pre morbid functioning
- Lack of social adversities.
Recurrence rate of postpartum depression
20-30%
How many women with postpartum depression will go on to have another, non-postpartum depressive episode
50%
Overview of family therapy
v Family Therapy see families as systems where every member’s
behaviour impacts on other members and this in turn changes
their behaviour which further impacts on other members.
v The system involves behaviour (what is said and done) and how
this is interpreted by each person and in turn how this influences
their behaviour and so on.
v Members of a family may not be aware of how the things they say
and do are understood and experienced by others nor the beliefs
and emotions that result.
v The aim is to avoid blame but to discover why people feel and
behave the way that they do and how this can be changed
through understanding the system of interactions and developing
strategies.
Structure of family therapy
v Ideally as many members of the family attend as are able but
therapy can occur with just two members and even on an
individual basis on occasion.
v A therapist is in the room with the family and will ask questions
and support discussion.
v Everyone is given time and space to express their view and answer
questions.
v In a separate room there is a therapy team who observe the
discussion and provide feedback or suggest other questions.
v The family can meet all members of the team.
v Therapy can take place weekly or less frequently and is usually
recommended over a period of 3 months.
Goals of family therapy
v The goals are for members of the family to gain an understanding
of how the others experience and think about their behaviour and
their emotional responses.
v In turn an understanding develops about how these perceptions
contribute to certain behaviours and how those are in turn
perceived by other members of the family.
What is high EE?
v High Expressed Emotion refers to a theory about the family
environment in terms of how other family members interact with
a patient and their attitude towards them. It describes a tendency
to be overly involved or overly critical of their relative with mental
disorder. Interactions will tend to be more hostile, intense,
oppositional and negative towards the patient. These kinds of
interaction, which are not unique to families with mental illness,
can be understood as an environmental stressor. This stressor can
increase the likelihood of a relapse. Examples could include
speaking in a raised voice, irritability towards the patient, blaming
them for their symptoms and expressing their experience of
burden as a care-giver. Similarly over-involvement in the patient
from feelings of guilt around their being unwell can have a
detrimental effect. This might take the form of overprotectiveness
or excessive self-sacrifice due to anxiety around the patient’s
illness. This may also prevent patients from having the freedom to
develop skills more independently.
Evidence of family therapy
Reduces rate of relapse of SCZ
Improves medication adherence in SCZ
What skills can family therapy teach?
Psychoeducation of SCZ Recognising precipitating factors and relapse signatures Structured problem solving Comm skills Stress management
How to assess appropriateness for family therapy
- Explore their experience as a care giver
- Ask about interpersonal behaviours and dynamics related to
challenges in care-giving (areas of disagreement or frustration
with the patient or another care-giver are key examples). - Appraise whether there is a willingness to accept alternative
explanations about others behaviour and that their personal
experience may be different to what is expected. - You can suggest that this misunderstanding others’ viewpoints for
each family member may lead to repeating problematic patterns
of interaction. - Appraise whether they can see a benefit from increasing their
understanding of how each family member experiences the others
and interacts. - After explaining what Family Therapy is and the kinds of things
that may be addressed, you can ask directly whether they think
this is something they could engage in.
What is CBT
Cognitive therapy is a way of helping people to cope with stress
and emotional problems. The idea behind it is quite simple –
‘the way we think about things affects how we feel
emotionally’. When people are depressed, they often have
negative thoughts about themselves, their future and the world
in general. These thoughts come automatically into their
minds. These negative thoughts or ‘cognitions’, undermine
their self-confidence, and make them feel even more depressed
leading to unhelpful behaviours. The therapist will work with
you to identify the thinking and behavioural patterns that
contribute to how you feel, and help you to make changes.
ü CBT looks at ‘here and now’ issues rather than things from the
past. It helps people to learn new methods of coping and
solving problems, which they can use for the rest of their lives.
