CASC Stations 4 Flashcards

Question

Risk factors for PND

Answer 1

1. Older Age 2. Single mother 3. Unplanned pregnancy 4. Personal history of depression 5. Family history of depression 6. Poor social support 7. Significant other psychosocial stressors

Answer 2

1. Personal history of major psychiatric disorder 2. Previous postpartum psychosis (30% risk of developing psychosis in the subsequent pregnancies) 3. Family history of major psychiatric disorder 4. Single parenthood 5. Lack of adequate social support

Answer 3

• 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

Answer 4

* Acute onset * Affective illness * Good social support. * First episode * Well adjusted pre morbid functioning * Lack of social adversities.

Answer 5

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.

Answer 6

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.

Answer 7

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.

Answer 8

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.

Answer 9

Reduces rate of relapse of SCZ | Improves medication adherence in SCZ

Answer 10

``` Psychoeducation of SCZ Recognising precipitating factors and relapse signatures Structured problem solving Comm skills Stress management ```

Answer 11

- 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.

Answer 12

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.

Answer 13

50 minute session once a week for 8-12 weeks In the first few sessions, the client and the therapist decide which problems seem to be the most important. Clients/patients take an active part and carry out ‘homework’ tasks between sessions. They will often be asked to keep a diary of their thoughts, feelings and behaviours in the situations that they find particularly stressful. They then discuss these in detail in the sessions with the therapists, asking themselves whether or not their ways of thinking are - realistic. They can then learn to change these ways of thinking to use more helpful ones. CBT helps by changing your thinking and behaviour patterns and in fact, the last few sessions focus on ‘relapse prevention’. Hence, it is effective in reducing the chances of relapse.

Answer 14

``` Catastrophising Labelling Dichotomous thinking Minimisation/magnification Selective abstraction Personalisation Overgeneralisation Arbitrary inference ```

Answer 15

Selectively picking failures and errors while ignoring positive features

Answer 16

Assuming personal responsibility for all that | has gone bad

Answer 17

Here the distortion leads to a global, over | generalized negative view of oneself;

Answer 18

Predicting without sufficient evidence

Answer 19

ü Psychodynamic psychotherapy is one form of talking treatments and is based on listening and talking. It involves exploring past conflicts (journey of self exploration) in relation to your current problems in order to make change possible ü It aims to treat people with long histories of serious emotional difficulties. These are linked to personal development, often over many years, and sometimes right from early childhood. The aim in psychotherapy is to look more deeply into the emotions, conflicts and distress behind your mental health diagnoses. ü There is a small possibility that you may feel worse before you feel better, as the therapy requires an uncovering of painful feelings and memories that be experienced as a relief but it may also stir up uncomfortable feelings.

Answer 20

ü A brief course of psychotherapy would last about three months, and a course of group therapy or long term individual therapy can last for a couple of years. ü Your motivation and relationship with the therapist is extremely important. The initial consultations aim to help think about this, in collaboration with a therapist. If you are well motivated and set yourself realistic goals, psychotherapy is likely to be of benefit. However the therapist can only offer guidance and the ultimate responsibility of changing is with the patient. ü It is offered on a weekly basis- same day, same time and same place Each session normally last fifty minutes and group therapy meetings are for one and a half hours.

Answer 21

In this therapy, first the patient will be taught relaxation exercises to help them control the anxiety and panic. Then we make a list of hierarchy of - situations that you find difficult to face. We arrange them from the least difficult to the most difficult and you may find it easier to face situations if you move from the least to the most difficult, Then you start by facing the easiest situation, whilst managing to relax. When you feel comfortable with that situation, you then go onto the next one. You will have to practice this daily. e.g. like going out of the front door of your house, going out to your garden from your house, then going out to a nearby shop with a family member/friend and then going out to a supermarket with a family member/friend and so on. ü Practice the steps until it no longer causes anxiety. Once you feel confident with one step, move on to a more difficult step and repeat the practice. ü If there are difficulties in getting out of the house, then we can arrange for the therapist to come to your house to help you initially. ü Your family members and or your partner have an important role in the treatment and it will be very helpful if they can also be involved to improve confidence and support them.

Answer 22

• This is a simple but highly effective technique • It is usually done in graded steps • The active participation of clients is necessary • The situation can be real or imagined (a real-life situation will be more effective) • It can be practised regularly with self-exposure tasks. • It is used particularly in treatment of phobias and OCD The treatment strategy involves exposing the individual to stimuli that trigger anxiety or discomfort, and then having the individual voluntarily refrain from performing his or her ritual or compulsion. For each ritual the individual will be required to list a range of situations that cause anxiety and The individual would then rate each of these situations according to the amount of anxiety or distress that would arise if he or she did not perform the particular ritual. These are then arranged in order according to those that generate the least anxiety or discomfort to those that generate the most anxiety or discomfort. The first task in the list would be an activity that is mildly discomforting but not too difficult, while the last task in the list would be the most difficult task that the individual can imagine. Before starting theses exercises, it is important to provide training for slow breathing exercises and relaxation. These exercises can be used prior to commencing each step of the graded exposure hierarchy to ensure that the individual is calm and relatively relaxed at the beginning of each graded exposure session.

Answer 23

The Cognitive component of CBT involves identify and modify maladaptive cognitions and seeks to reduce to suppress and avoid Obsessional thoughts. The Behavioural component involves Behavioural techniques such as exposure and response prevention which would be exposing the individual to those situations that triggers anxiety (or) discomfort and refrain the individual voluntarily from performing his (or) her ritual. The therapist works with the patient and helps the individual plan a graded programme of exposure tasks. These anxiety provoking situations are then arranged in order according to those that generate the most anxiety (or) discomfort (hierarchy of tasks) the patient is also provided training for relaxation and taught one step to the next until the person can mange the last step with minimal anxiety without getting anxious. The situation can be real (or) imagined (a real life situation will be more effective), usually done in graded steps and can be practiced regularly with self-exposure tasks.

Answer 24

• The focuses of treatment are the current interpersonal relationships and their relationship to the development of illness. • Emotional problems are best understood by studying the interpersonal context in which they arise. • It does not make any assumptions about the causation of the illness, but aims to use the connection between the onset of depressive symptoms and the current interpersonal problems as a focus of treatment • Resolving the interpersonal problem is seen as a route to recovery.

Answer 25

The four interpersonal areas related to illness development include: a. Grief (loss of a loved object/relation) b. Interpersonal disputes e.g. Conflict with family members, colleague or a friend c. Change of role (e.g. graduation, new mother, retirement, job loss, medical ill health) d. Interpersonal deficits.(inadequate interpersonal relationships)

Answer 26

• It is time-limited • Treatment lasts for 12-16 hour long weekly sessions, offered by trained therapist • The therapist starts with a diagnostic phase, in which the disorder is identified and explained. Inventory of all close relationships is created in early part of therapy. • The therapist will now try to link the depressive symptoms with one of the four interpersonal areas and will pursue strategies specific to one of these problem areas. • The therapist is directive and takes an active & supportive stance. • The patient is encouraged to identify and carry through change in interpersonal relationships and to test the possibility of consequent improvement in their symptoms. • The final phase involves assessment of improvement and develops ways of identifying and countering depressive symptoms, should they recur in the future and plan for termination of therapy.

Answer 27

Interpersonal Psychotherapy (IPT) is a form of structured psychotherapy • It is time-limited that is normally delivered over 12-16 weekly sessions. • IPT focuses primarily on relationship problems. It helps people recognise the problems they face with other people and to make changes in their relationships. • IPT looks at the ways in which a person’s current difficulties in relationships contribute to their psychological stress, and in turn looks at the ways psychological problems affect relationships. • When an individual can deal with relationship problems more effectively, their psychological symptoms often improve.

Answer 28

During the first few sessions, the therapist will be talking with your about your depression and current important relationships to see how they are linked You will work with your therapist to complete an Interpersonal Inventory, which is basically a review of your key relationships, looking at their strengths and problems and how other might be able to assist you in your recovery. This will help you to identify those relationships, which it would be most useful to focus on during therapy. You will agree a contract with your therapist, outlining the focus of the work for the remaining sessions.

Answer 29

During the middle sessions of treatment, you and your therapist will discuss your agreed main area of interpersonal difficulties and work on making positive changes. There are several tasks assigned during these sessions. This will include a) monitoring current relationship triggers for depression b) working on improving communication, and c) discussing your emotional reactions to your relationship problems. You might decide to invite someone who is important in your life to one of these sessions to help them to understand and support you in the work you are starting to do.

Answer 30

In the last few sessions, you and your therapist will discuss feelings about therapy ending and the progress you have made during the treatment. The therapist will spend some time with you planning ahead for any other problems you anticipate in the future and how to use the new skills and supports you have developed.

Answer 31

sedation, hypersalivation, constipation, | hypotension, tachycardia and weight gain

Answer 32

4-18 weeks

Answer 33

Consider detailed USS in first trimester Risk of neonatal withdrawal syndrome Breast feeding not advised due to high conc in breast milk

Answer 34

Four fold risk compared to gen pop

Answer 35

v Physical examination: Weigh patients, check blood pressure, waist circumference and track BMI at each visit v Take a history and record whether known risk factors are present or absent at baseline and monitor at regular intervals v Perform baseline laboratory tests including fasting glucose, fasting lipids, total cholesterol, Low density lipoproteins (LDL), high density lipoproteins (HDL), triglycerides, alanine aminotransferase (ALT) and gamma glutamyl transferase (GGT) v The choice of antipsychotic medication should be based on the cardio metabolic risk profile of each medication v Perform Physical examination and Repeat Laboratory tests at week 6, week 12, week 52. After 1 year if all the laboratory tests are within normal range, repeat tests annually

Answer 36

OGTT or FPG, HbA1c if fasting not possible at baseline and every 12 months

Answer 37

Those on clozapine or olanzapine; fasting lipids every 3 months for a year then annually Other antipsychotics; fasting lipids at 3 months then annually

Answer 38

``` Thirst, polyuria Blurred vision Dry mouth Metallic taste Fine tremor of hands ```

Answer 39

``` Weight gain Kidneys Thyroid - hypothyroid Tremor Skin rash ```

Answer 40

``` Severe tremor Vomiting Diarrhoea Blurred vision Slurred speech Lack of coordination Confusion Muscle twitching ```

Answer 41

FBC, U&Es, TFT, ECG

Answer 42

Lithium plasma levels after 5-7 days then every week until therapeutic reached, then every 3 months Renal, thyroid and ECG every 6 months Lithium card to carry all the time

Answer 43

Fluid balance Stop if toxicity suspected and contact GP Avoid overexercise or salt free diet Women - contraception

Answer 44

70% in 6 months

Answer 45

Nausea, weight gain, tremors, hair loss | Thrombocytopenia

Answer 46

Sedation, low BP, dry mouth, constipation, blurred vision, urinary retention, EPSEs, weight gain

Answer 47

``` Drowsiness Weight gain Hypotension Impaired glucose tolerance Constipation ```

Answer 48

``` Weight gain Increased prolactin Headache Nausea EpSEs ```

Answer 49

Weight gain Dry mouth Drowsiness Postural hypotesion

Answer 50

Insomnia Nausea Constipation Increased prolactin

Answer 51

``` Sediation Low BP Dry mouth Blurred vision Urinary retention Weight gain Arrhythmia ```

Answer 52

``` Nausea Abdominal pain Sweating, anxiety Insomnia Sexual dysfunction ```

Answer 53

The exact mechanism of how it works is not known. During ECT, a small amount of electric current is passed across your brain. This current produces a fit/seizure, which affects the entire brain including centres that control thinking, mood, appetite and sleep. Repeated treatments alter the chemical imbalance in the brain and bring them back to normal. This helps you begin to recover from your illness.

Answer 54

An ECT treatment involves having an anaesthetic. The anaesthetist will ask you to hold out your hands so you can be given an anaesthetic injection. It will make you go to sleep and cause your muscles to relax completely. You will be given some oxygen to breathe as you go off to sleep. Once you are fast asleep, a small amount of electric current is passed across your head and this causes a mild fit/seizure in the brain. There are little movements of your body because of the relaxant injection that the anaesthetist gives.

Answer 55

80% of depressed patients improve

Answer 56

8-10 sessions given twice a week

Answer 57

0.12-0.2seconds | 3-5 small squares

Answer 58

<0.12seconds/<3 small squares

Answer 59

Leads I, II and V4-6

Answer 60

``` Female Children and elderly Severe exertion Anorexia IHD/LVH/MI/Long qt syndrome Low K+, Calcium or Mg2+ ```

Answer 61

Antipsychotic/antidepressants/Abx Cardiac FHx Symptoms - CP, SOB, LoC, dizziness Diabetes/HTN/cardiac hx/smoking

Answer 62

1. Physical illness- diabetes, cardiovascular complications 2. Psychiatric illness- depression 3. Relationship difficulties 4. Substance misuse 5. Prescribed drugs such as SSRIs, venlafaxine etc

Answer 63

v Watchful waiting- to see if symptoms subside. Spontaneous remission- seen in 10% of cases and a partial remission in 11% v Reduction in dose of offending drug should be tried first (Dose alteration) v If no response, discontinuation of the antidepressant and possible switch to a different drug less likely to cause sexual dysfunction should be tried. (Sexual side effects are less common with Reboxetine- 5-10%, Mirtazapine- 25%, Bupropion). Bupropion is used as a first line drug in USA with minimal risk of sexual adverse effects and as an adjunct & antidote in patients with SSRI induced sexual dysfunction. (Not licensed in UK) v Other options- Addition of another agent to counteract the sexual side effects (‘Comination’ eg mirtazapine, bupropion, or ‘As required’ eg sildenafil, cyproheptadine, amanatadine, yohimbine etc. Other drugs of use- Selegiline transdermal patches, Sildenafil (Viagra) and Agomelatine. Sildenafil is more effective than placebo at improving erectile dysfunction in men and in improving sexual function in women taking SSRIs

Answer 64

Explore current problems and obtain more history (Mode of onset, duration, progression, precipitants if any) Acknowledge the difficulty in talking about Sexual problems, Reassure-common and could be treated Agree to speak to his partner Elicit briefly Symptoms of depression (Low mood, anhedonia, Fatigueability, disturbed sleep etc) Obtain detailed sexual history (Lowered libido, Arousal difficulties, Reaching orgasm too soon or Failure, Erectile failure, inability to maintain erection etc) Identifying possible triggers for sexual problems (Physical, psychological- ? depression, Environmental factors, Factors related to the partner) Addressing concerns- 1. Longer term effect of medication on sex life 2. Risk of stopping meds- not advisable

Answer 65

a. Avoid late evening exercise; reduce caffeine (or) alcohol intake/smoking, excessive daytime sleep and napping, large late meals and thinking about problems before going to bed. b. Encourage bed time routines, regular exercise (not in the evening), routine of rising and retiring at the same time each day, use anxiety management (or) relaxation techniques and sleep environment should be quiet, familiar and comfortable. c. Other measure like relaxation techniques, anxiety management, medication, yoga, listening to relaxation cassettes.

Answer 66

tachycardia, irritability, restlessness, diaphoresis initially followed by the later development of hallucinations, tremors, insomnia, confusion, nausea, hypertension after 3-6 hours. After 12-48 hours seizures, confusion, hypervigilance can occur. The life threatening complications are those of acute renal failure, rhabdomyolysis, excited delirium, catatonic stupor and seizure.