Principles of management in mental health Flashcards
What should a risk assessment include?
Self harm , Suicide , Finances, Physical health/neglect, Medications, Nutrition, Mobility and falls, Driving, Fire, Aggression to others, Children/caring responsibilities
History of risk behaviour, insight and pkanning, impact on patient, impact on others, protective factors
3 Ps risk assessment factors
Precipitating factors, protective factors, perpetuating factors
1-7 risk assessment ‘history’
1-7: 1, demographics – age, sex/ 2, FH/ 3, Mental illness, symptoms, insight. 4, MSE. 5, Alcohol, illicit substances. 6 – Previous behaviour. 7 – recent incidents eg self harm
What does a formulation do?
Guides individualised management for patients. Descriptive summary – key features history, MSE, risk. Differential diagnosis. Aetiology, investigations, management (short and long), prognosis
What aspects of aetiology consider in a formulation?
Predisposing, perpetuating, precipitating. BPS (3 Ps for each)
What do you include in psychological part of formulation?
Temperament, IQ, Self esteem, coping skills, social skills, family relationships, trauma
What do you include in social aspect of for,ulation?
Drug effects, peers, family relationships, trauma, family circumstances, school
What do you include in the biological aspects of a formulation?
Physical health, disability, genetic vulnerabilities, termperament, IQ, drug effects
Neuroimaging investigations when diagnosing a psychiatric concern Strucutral vs functional?
Structural – CT, MRI
Functional – SPECT, PET, DAT
CT head indications?
Focal neurological signs, confusion developing after head injury, evidence of raised ICP
EEG indications
Differentiating delirium from dementia OR non convulsive status epilepticus OR temporal lobe epilepsy
Lumbar puncture indications
Sus meningitis/encephalitis
Aims of treatment of metnal heatlh
Treat acute problems, promote recovery and prevent relapse
What to consider when considering medication Regular or PRn
Side effects, concordance, safety
What to consider when thinking of physical treatments for psychiatric conditions
Treatment of other conditions, review of meds, ECT, drugs and alcohol, prescribed meds, phyiscial illness
3 groups of psychological interventions
Investigative eg formulation. Formal therapies – individual and group. Counselling and support incl voluntary sector
Types of psychological therapies
CBR, Interperonal therapy incl effective brief therapy, Cognitive analytic therapy, couple therapy, family therapy, DBT, EMDR, Cognitive stimulation therapy, psychoanalytic psychotherapy
Alternative to CBT on NICE
Effective brief therapy (type of interpersonal therapy)
When is DBT esp helpful?
Personality disorders esp BPD esp if recurrent self harm and female
What therapy can be used to improve dementia?
Cognitive stimulation therapy
What happens in psychoanalytic psychotherapy?
Reflect on thoughts and feelings, explore how events from past (esp early life) affect current thoughts and feelings, therapist helps patient make connnections
What are the indications for psychoanalytic psychotherapy?
BPD, chronic depression, personality difficulties when interpersonal factors prominent
How long does psychoanalytic psychotheraoy continue for?
Weekly session for 12-18 months
Types of social interventions
Behavioural activation, voluntary work, return to employment, meal provision, carers, support re-mobility, spiritual needs, hobbies + activities, engaging with friends and family
What social prescribing examples would strengthen psychosocial, life and coping skills of individuals?
Community education froups, arts/learning/exercise referral, self help groups/resources, CCBT, bibliotherapy
What impact do interventions that aim to strengthen psychosocial, life and coping skills have?
Promote self expression, self efficacy, self esteem, opportunities to learn new skills, stress/anger/anxiety management and relaxation
What do interventions that increase social support as a buffer against adverse life events aim to do?
Help build social contacts through self help groups, netwirsm collective action and opportunities for new friendships
Examples of social interventions aiming for social support
Self help groups, group activities eg walking, green gyms, volunteering, time banks
What interventions increase access to resources and services which protect mental wellbeing
Signposting to information+ advice eg debt, benefit, housing, immigration, violence and crime, Support with seeking help, supported education/employment, time banks
What is personality?
Personality is a complex set of characteristics that make us who we are – typical behaviours, coping, attitudes towards ourselves and others. Thinking, feeling and behaving patterns.
What is an adverse childhood experience?
Traumatic events that can have negative, lasting effects on health and wellbeing
Types of ACEs
Abuse – emotional, physical, sexual. Neglect – emotional, physical. Household challenges – domestic violence, substance abise, mental illness, paretnal separation/divorce, incarcerated parent
How much of the population have >4 ACEs?
1 in 8
How much earlier do people with >6 ACEs die than those with none?
20 years
How much of the population have at least one ACE?
67%
How do ACEs lead to earlier death?
ACE -> Disrupted neurodevelopment -> social, emotional, cognitive impairment, adoption of health risk behaviours -> disease, disability, social problems -> early death
What do ACEs increase the likelihood of?
Injury, mental health (depression, anxiety, PTSD, suicide), pregnancy – unintended, complications, foetal death), infectious disease, chronic disease (cancer, diabetes), risky behaciours (alcohol+drug abuse, unsafe sex), opportunities – education, occupation, income.
What stress is considered healthy?
Stress that helps us respond to temporary challenges in our life – race etc. Stress response activates and quickly returns to baseline
When can intense or longer lasting stressors be tolerable?
Support systems in our lives to help us cope
When is stress considered toxic?
Severe or frequent exposure to stress -> toxic on body and brain
What systems does stress affect in the brain?
HPA axis, emotional processing and regulation in prefrontal cortex and amygdala, evaluation of reward ventral striatum, brain connectivity from amygdala to ventromedial PFC pathway
Where is the stress pathway based?
HPA axis, hippocampus
Affect on the stress pathway in chronic stress?
Dysregulated HPA axis and decreased hippocampal volume leading to anxiety, depression and impaired learning and memory
What brain changes cause hypervigilance and reduced attentional control in toxic stress?
Decreased grey matter in the prefrontal cortex + increased amygdala volume – dysregulated emotional processing
What happens to the reward response in toxic stress? Where is it based>?
Decrease reward response in ventral striatum leading to anhedonia. Difficulty experiencing joy
What biological changes to brain connectivity does toxic stress cause?
Disrupted amygdala to ventromedial Prefrontal cortex pathway, decreased activity in the default mode network, increased activity in salience networks
What does toxic stress affect on brain connectivity cause?
-> difficulty understanding relevance of situations and how to respond
Why do some people develop a disorder after experiencing ACEs and others don’t?
Work through experience not just exposure – if ACE prevented from causing toxic stress, harm should not occur – presence of resilience
Why do some people develop a disorder after experiencing ACEs and others don’t?
Work through experience not just exposure – if ACE prevented from causing toxic stress, harm should not occur – presence of resilience
What is the significance of resilience in relation to ACEs?
Ability to thrive, adapt and cope despite tough and stressful times – counterbalance to ACEs. Evident when childs health and development tips toward positive outcomes, even when heavy load stacked on negative outcome side
What is the significance of the attachment theory?
It shows the importance of a childs relationship with their primary caregiver in terms of their social, emotional and cognitive development. Important to remember attachment styles are also influenced by other experiences/influences that shape us as we develop
What can cause later maladjustment in terms of primary caregiver and child?
Early separation
What are the severities of personality disorder on ICD 11?
Mild, moderate, severe
What predominant traits can be assigned to personality disorders on ICD 11?
Negative affectivity, detachement, dissociality, disinhibition, anakastia, borderline pattern
Option for personality difficulty
What has to be present for the diagnosis of personality disorder?
Enduring disturbance from adolescence characterised by problems functioning of aspects of: the self, interperonsal dysfunction, > 2 years, patterns of cognition, emotional experience, emotional expression, beahviour that are maladaptive, range personal and social situations, not developmentally appropriate or better explained by primary social or cultural factors, not due to medicine or substance or another disorder, ass with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning
What makes a personality disorder severe?
Severe disturbances in self function, interpersonal dysfunction seriously affect all relationships/ability + willing to perform expected social and occupational roles. Specific manifestations of personality disturbance are severe and affect most areas of personality functioning, often ass with harm to self or others, ass with severe impairment in nearly all areas of life
What areas of life can be impaired in personality disorders?
personal, family, social, educational, occupational, and other important areas of functioning.
What is the definition of negative affectivity trait in personality disorder?
Tendency to experience a broad range of negative emotions with a frequency and intensity out of proportion to the situation
What is the definition of detachment trait in personality disorder?
A tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment)
What is dissociality trait definition?
Disregard for rights and feelings for others, encompassing both self-centredness and lack of empathy
What is the definition of disinhibition trait?
A tendency to act rashly based on immediate external or internal stimuli (ie sensations, emotions, thoughts) without consideration of potential negative consequences
What is anakastia trait definition?
Narrow focus of ones rigid standard of perfection and of right or wrong, and on controlling ones own and other behaciour and controlling situations to ensure conformity to these stadnards
What are the features of negative affectvity?
Anxiety, anger, worry, fear, vulnerability, hostility, shame, depression, pessimism, guilt, low self esteem, mistrustfulness
What are the features of social detachment?
Avoidance of social interactions, lack of friendships, acoidance of intimacy
What are the features of emotional detachment?
Being reserved, aloofness, limited emotional expression and experience eg individuals seek out employment that does not involve interactions with others
What are the features of dissociality trait?
Self centredness – entitlement, grandiosity, expectation of others admiration, attention-seeking. Lack of empathy - deceptive, manipulative, exploiting, ruthless, callus, ohysically aggressive, sometimes pleasure in others suffering
What are features of disinhibition trait?
Impulsivity, distractibility, irresponsibility, recklessness, lack of planning. Often engaged in reckless driving, sports, substance use, gambling, unplanned sexual activity
