Other

Question 1

How would you assess a patient presenting with self-harm/suicide attempt
Before
During
After
Others:

Answer 1

Before: Premeditation/planned?, Suicide note, last acts (giving something away), Alone/isolated (locked doors/closed curtains), Anyone in the house? What might have motivated you?
During: Perceived lethality, precautions to avoid discovery (alone?)
After: Attempt to seek help, How did you feel after taking the pills?, Regret? Or continued desire to die?, Continued access to means to re-attempt
Other: Past psych history!

Question 2

What is involved in risk assessment?

Answer 2

Risk to self: Suicidal ideation, attempt, risk of falls, risk to reputation, occupational risk,
Risk to others: Children (including neglect of child!!!), access to weapons, convictions (forensic!!), Financial risk to dependents, Risky behaviour
Risk from others: Exploitation from family or friends (important in schizo and mania)
Self-neglect: Medical, financial, hygiene, food/fluid intake
Risk during admission: Non-compliance/refusal of treatment, aggressive to staff, stalking staff, accusing staff (complaints), risk of absconding

Question 3

What is ECT. Define it.

What are its indications?

Answer 3

ECT or electroconvulsive therapy is a last-line therapy and involves running an electric current into the temporal lobe causing a tonic-clonic seizure.

Indications:
Severe depression that has been resistant to at least 2 other forms of tx/very high risk/previously responded well/unsafe such as in pregnancy (8 in every 10 patients with treatment resistant depression show promising results on ECT)
Bipolar resistant to tx
Short term symptom reduction is schizophrenia/schizoaffective disorder such as catatonia or neuroleptic malignant syndrome
Maintenance ECT

Question 4

Describe the Pre-operative workup for ECT:

Once that is complete, how is it administered?

Answer 4

Pre-op
1. Written and verbal explanation from psychiatrist + Capacity assessment for consent (or MHA)
2. Full medical history and physical exam + Bloods, U&E etc…
3. Pre-procedure assessment from anaesthesiology

Op:
1. Continuos measure and monitoring of ECG, EEG, and O2 sat
2. Electrode placement is bitemporal (if bilateral) and non-dominant temporal + occiput (if unilateral)
3. Patient must be fasting and the anaesthesiologist will administer short-acting IV anaesthetic + muscle relaxant + mouth guard
4. Minimum dosage to cause a tonic clonic seizure is calculated in milicoulombs (to minimize side-effects)
5. Length of convulsion (visual) and seizure (EEG) are measured typical = 20-40s

Question 5

What are the contraindications of ECT?

Answer 5

There are no contraindications for ECT but it is usually deferred if the patient isnt stable or if there is a general serious medical condition such as brain tumour, recent ICH (intracerebral haemorrhage), or unstable arrhythmia

Question 6

A patient asks you about his ECT sessions so he could inform his work about the days he will have to take off. What will you tell him?

Answer 6

ECT is normally administered 2 times a week for a total of up to 12 sessions. (On average, it takes 6-8). If sufficient recovery is observed then it will be reduced onto maintenance ECT if indicated. In that case, it would be every 2-4 weeks.

Question 7

Give 3 intended effects of ECT. (What does it do to your brain)

What are the side effects?

Answer 7

It causes 3 improvements:
1. Enhances Serotonin, Noradrenaline, and Dopamine transmission
2. Restores Dexamethasone suppression (steroid med used in rheumatic problems)
3. Increases Limbic connectivity and neural growth in Amygdala and Hippocampus

Side Effects:
Immediate: Headache + Muscle ache
Short Term: Retrograde Amnesia (reduced in unilateral) that resolved within weeks. Reduced in unilateral ECT and hence memory must be assessed via MMSE in between sessions
Rare: Death (1 in 70,000). These deaths are usually related to CHD rather than the ECT itself
Occasionally a patient with bipolar depression may become elated after ECT

Question 8

You are meeting patients that require ECT. Modify their medications if needed giving explanation for why (even if you didnt change)
Patient A: Benzodiazepines
Patient B: Anticonvulsants given for epilepsy
Patient C: Antidepressants

Answer 8

Patient A: Benzos increase seizure threshold => must be stopped night before ECT
Patient B: If anticonvulsants are given for epilepsy they may be continued
Patient C: Antidepressants and other medications are continued to prevent relapse

Question 9

Define psychoeducation including what it entails

Answer 9

involves teaching a patient about their own illness and including them in their own treatment plan. Also includes teaching patient how to manage it, how to recognise signs of relapse (relapse signature). May also be provided to family/support system (friends)

Question 10

Define Supportive Therapy including what it entails.

Answer 10

Therapist acts as support to allow the patient to reflect on their life situation in an environment in which they are accepted. They help in clarification, explanation of symptoms, expression of thoughts and ideas, guidance of discussion and provide active listening and reassurance.

Question 11

Define CBT

Answer 11

CBT is a therapy based on the theory that psychological symptoms are related to the interactions of one’s thoughts and emotions, behaviours, and biological/physical symptoms. This allows direct challenge to the thoughts and behaviours that are maintaining/perpetuating their psychological symptoms.

Overall, Breaks down problems into individual components (of thought, emotion, behaviour, and physical symptoms) and uses cognitive restructuring to reinforce good behaviours while challenging bad ones.

Question 12

CBT employs a method called Cognitive restructuring. What does that entail?

Answer 12

Allowing the patient to be aware of their cognitive distortions and their associated behaviours. Restructuring these thoughts will lead to restructuring the way they behave in situations causing distress.

Question 13

What are the components of a problem as described in CBT (4)

Answer 13

Thoughts, emotions, behaviours, and physical symptoms

Question 14

Define Behavioural therapy

Answer 14

Behavioural therapy uses classical and operant conditioning to replace maladaptive or self-destructing behaviours by learning new behaviours using the ABC Approach (Antecedents, behaviour, and consequences)

Question 15

What is the ABC approach used in Behavioural Therapy?

Answer 15

Antecedents, behaviour, and consequences. AKA before the behaviour, the behaviour itself and the consequences of the behaviour

Question 16

What does thought stopping entail? What type of therapy utilises this technique? Where it is used?

Answer 16

Thought stopping is a technique used in behavioural therapy to treat obsessions in patients with OCD. Whenever an unpleasant thought enters their mind, they replace it with a healthy and rational one such as yelling stop until the thought ceases.

Question 17

What are the indications of DBT. Explain how it would benefit people with this condition.

Answer 17

Used in Personality disorders with borderline pattern and eating disorders. People with these disorders tend to react abnormally (Black and white thinking) to emotional stimulation often due to the environment they were in during their upbringing.

Question 18

Define Interpersonal therapy including indications

Answer 18

This therapy uses unconscious psychodynamics of emotional conflict and focuses on current interpersonal relationships as well as the relationship with the illness itself.
Indications: Post-natal depression, bipolar, eating disorders, unresolved grief (with actual symptoms)

Question 19

What does desensitisation therapy entail including indications. What type of psychotherapy does it fall under?

Answer 19

Desensitisation therapy is a type of behavioural therapy based on classical conditioning that involved exposing the patient to dear-evoking images and thoughts or actual exposure while pairing it with relaxation exercises to descrease their fear response.

Used in agoraphobia, panic attacks, specific phobia, social anxiety disorder, and selective mutism

Question 20

What does stimulus fading entail. What is it indicated for

Answer 20

Person communicates with someone at ease such as their parent and then another person is introduced and once theyre included, the parent withdraws and another person is introduced

Question 21

What does EMDR stand for?
What does it entail?
Where is it indicated?

Answer 21

Eye Movement Desensitisation and Reprocessing
Therapy that incorporates CBT with bilateral eye movements (such as following doctors finger) that is rhythmic in nature while patient is asked to talk about the issue/trauma
Indicated in PTSD/Complex PTSD

Question 22

What does Activity Pacing and Graded Physical Exercise therapy entail? What is it indicated in?

Answer 22

Programme of rest and relaxation along with graded activity to work out the baseline of the patient in terms of rest and activity that they can do everyday consistently with discipline.
Indicated in Bodily Distress Disorder

Question 23

What does Biofeedback therapy entail?
What is it indicated in?

Answer 23

Utilizes operant conditioning to establish voluntary control of physiological responses of the ANS such as BP, HR, and muscle tension. Changes in these are made noticeable to the patient via LED or audio. The patient will learn to recognise when physiological changes occur while learning how to consciously relax to bring back balance to the body
Indicated in Bodily Distress Disorder

Question 24

You are asked to assess capacity of a patient. Go through the 6 components. How many of these criteria need to be present for the person to be considered to have capacity?

Answer 24

1. Understand: Patient must understand the problem they have, purpose of tx, and risks of having and not having tx
2. Believe: Patient must believe the medical opinion is correct, genuine, and applies to them. What do you think the problem is?
3. Retain: Patient must retain info long enough for judgement (ask to summarise)
4. Use: Patient must use info to make a decision (ask directly what their decision is)
5. Weigh in the balance: Patient is able to weigh risk vs benefit of tx
6. Communicate: Can communicate their reasoning behind their decision

A patient requires all of these components to have capacity.