Physical/psychological treatments Flashcards
How does ECT work?
Neurochemical theories: Chanes in receptor expression of D2 and 5-HT2 receptors
Neuroendocrine theories: Restores diurnal rhythm of HPA axis, plus enhances production + release of several neuroendocrine substances (e.g. oxytocin)
Neuro + synaptogenesis: Increase in BDNF and synaptic remodelling seen in animal data
Connectivity: Changes in connectivity between dorsolateral prefrontal cortex and subgeniculate cortex
Indications for ECT
Severe depression: Stupor, life-threatening, treatment-refractory
Moderate depression: Prolonged, resistant to multiple drugs + psychotherapy
Mania + psychosis: Prolonged/severe
Catatonia/NMS
Physiological effects of ECT
Raised pressures: Intraocular, intragastric, hypertension
Dental: Supraphysiological bite
Cardiac: Emergent arrhythmias
Endocrine: ACTH, cortisol, glucagon release –> may affect blood sugar
Efficacy of ECT
High remission rates, but short-lived (approx 2w) –> need to include supplemental management after course of CBT
90-95% for puerperal psychosis
80-85% for unipolar depression
80% catatonia
70-75% bipolar
Side effects of ECT
- Immediate:
- Headache
- Nausea
- Muscle ache
- Confusion/disorientation
- Longer-term
- Antero- + retrograde amnesia for duration of treatment + following month
- Deficits in autobiographical memory up to 6mo before treatment (RARER, 15-20%)
- Rare but severe:
- Emergent hypomania
- Bone/dental/jaw injury
Length of ECT treatment
Twice a week, usually for 6-12 sessions (3-6w)
Consent and capacity frameworks for ECT
Voluntary:
- Capacitous –> need consent
- Lacks capacity –> need assent
Detained:
- Capacitous –> need consent (c.f. pharma treatments)
- Lacks capacity –> needs SOAD (no 3-month rule)
Contraindications for ECT
No absolutes, but several cautions
Cerebral: Raised ICP, cerebral haemmorhage, stroke, aneurysm, glaucoma/raised IOP
Cardiac: Recent MI, arrhythmia, phaeochromocytoma, malignant hypertension
Unstable COPD/chest infexion
Principles of rTMS
Repetitive transcranial magnetic stimulation
Pulses of strong magnetic field applied to excite/inhibit cortical pyramidal cells in a more localised fashion compared to ECT (esp dorsolateral prefrontal cortex)
Timecourse of rTMS treatment
45-min sessions (may be optimised with shorter, theta-burst rTMS)
5x per week
For 4-6 weeks
Presents logistical barrier
Efficacy of rTMS
For treatment-resistant depression: 1:1:1 recovery/partial recovery/no effect
Side effects of rTMS
Headache, facial discomfort
Syncope occasionally
Rarely seizure induction
Contraindications for rTMS
Epilepsy, stroke, brain tumour
Three levels of cognition in CBT model
Automatic thoughts: Rapid images/verbal interpretations of events –> often taken as true although not necessarily correct
Dysfunctional assumptions:‘Rules’ for behaving and interacting with world
Core beliefs: Absolute statements about self, others, world that shape how we view the world
These are explored in the formulation of CBT
Common negative cognitive biases
All-or-nothing thinking
Catastrophising
Overgeneralising
Disqualifying positives/focusing on negatives
Labeling/jumping to conclusions
Personalisation
Rationale behind CBT
Cognition, emotion, behaviour, and physical sensations co-exist and influence each other
Influencing cognition/learned behaviorus –> influence on emotions/physical sensations leading to improvement
Principles/tools of CBT
- Thought diaries: Allow breakdown of unhelpful thinking patterns + identification of trends/core beliefs
- Socratic questioning: Challenging cognition w/ support of therapist as collaborator (not as expert) –> pt reaches own conclusions
- Behavioural experiments: Desensitisation by breaking link between thought and conclusion
Stepped care model for psychological treatment
Step 1: Assessment, psychoeducation, monitoring, possible referral to IAPT (i.e. Talking Space for steps 2-4)
Step 2: Low-intensity CBT e.g. computer-based, guided self-help, group CBT, motivational interviewing
Step 3: Individual CBT, counselling, IPT
Step 4: Intensive, specialist CBT/IPT/DBT/CAT
Four areas of focus of interpersonal therapy
One of:
- Grief
- Managing transitions
- Interpersonal deficits (social impoverishment)
- Interpersonal disputes
What is DBT?
Dialectical behaviour therapy
Used for BPD patients
Skills in coping with emotional distress and problem-solving, allow more adaptive responses
Techniques of DBT
- Individual:
- Validation of emotions
- Identifying maladaptive behaviorus + their triggers
- Reinforcing adaptive behaviours
- Group:
- Mindfulness techniques
- Emotional modulation techniques
- Interpersonal skills: e.g. communication, conflict resolution
- Distress tolerance skills: Self-soothing, distraction
- Other:
- Telephone between sessions for ‘real-life’ application
- Therapist support groups
Uses of motivational interviewing
Substance abuse
Risky behaviour in adolescents
Smoking/substance use in pregnancy
Behavioural change desired (e.g. in ED)
Role of supportive psychotherapy
Recent onset problems: Short-term support to weather transitions/adjustment
Mild depression (Esp if one episode, trigger known)
Mild-moderate anxiety
Techniques in systemic family therapy
60-90min every 2-4 weeks
One therapist + reflective team behind one-way screen, or two therapists reflecting in front of family
Highlight strengths, share ideas, find solutions
Concerned with:
- Power distribution within system
- Communication
- Attachment
- Intergenerational scripts/roles
