Psychological treatments And Therapeutics Flashcards
When do NICE recommend ECT to treat depression?
Severe depressive episodes that are life threatening or require rapid response
Short term side effects of ECT
Headache
Muscle pain
Nausea
Temporary memory loss
Confusions
Long term side effects of ECT
Persistent memory loss
Risks of ECT due to induced seizure
Damage to teeth and mouth
Risk of GA
Small risk of death
Possible indications for ECT?
Treatment resistant depression, or severe depression in which there is a need for rapid antidepressant effect.
Severe treatment-resistant mania.
Catatonia.
Severe depressive illness
bipolar disorder,
schizophrenia,
schizoaffective disorder,
catatonia,
neuroleptic malignant syndrome
Examples of medications used to manage ADHD
Central nervous stimulants:
Methylphenidate (“Ritalin“)
Dexamfetamine
Atomoxetine
Children with ADHD managed by Methylphenidate required what monitoring and why?
It can cause growth retardation, weight loss, tachycardia, and hypertension.
As such, children taking this medication need to have their height, weight, heart rate and blood pressure measured every six months.
What is ERP and how is it used to manage OCD?
ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands).
This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
IAPT appropriate presentations
Depression
Social phobia
GAD
Panic disorder +/- agoraphobia
Mild OCD
Specific phobia
PTSD - single trauma events
Health anxiety
Long term health conditions impacting mental health
Loss including miscarriage, abortions or still births
IAPT exclusion criteria
Bipolar
Psychosis
Personality disorders
Eating disorders
Anger management
Substance misuse where the person is reliant on a substance for day to day function and is working with a local substance misuse service
‘Would like support or someone to talk to’
Potential side effects of ECT
Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia
Seizures leading to muscle aches (muscle relaxants given for this)
bleeding from ulcers
PE
subconjunctival haemorrhages
Long-term side-effects
some patients report impaired memory
broken teeth
raised IOP
Risks of anesthesia: MI, arrythmias, aspiration pneumonia, prolonged apnoea, neausea, adrenocortical supression with etomidate, mallignant hyperhtermia, muscle aches, death
When might ECT be used?
Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.
Contraindication against ETC
The only absolute contraindications is raised intracranial pressure.
Aspects/principles of dialectical behavioural therapy (DBT)
mindfulness
acceptance
distress
tolerance
emotional regulation
What is psychotherapy?
Psychotherapy is the systematic use of a relationship between a patient and a therapist - as
opposed to physical and social methods - to produce changes in feelings, cognition and behaviour.
Common features of all psychological therapies?
- An intense confiding relationship with a helpful person (the therapeutic alliance or
therapeutic relationship lies at the heart of all psychotherapeutic approaches) - A rationale containing an explanation of the patient’s distress
- The provision of new information about the nature and origins of the patient’s problems and
the ways of dealing with them - The development of hope in the patient that they will be helped
- Opportunities to experience success during treatment, enabling an increased sense of
mastery - The facilitation of emotional arousal
Which psychotherapies are available on the NHS?
Psychodynamic Psychotherapy
Behavioural and Cognitive Psychotherapies (cognitive-behavioural therapy or CBT)
Interpersonal Therapy (IPT)
Family/systemic therapies
In which settings can psychotherapies be delivered?
CBT and psychodynamic/analytic therapies can be delivered to individuals (i.e. one therapist and one
patient) or in groups (usually around 8 patients with one or two therapists).
Some work is most
appropriately done with a patient couple (e.g. in marital or psychosexual work).
Systemic therapies
ideally work with all those viewed as parts of the system (e.g. an extended family).
Psychotherapeutic
work can be undertaken in day centres/hospitals and sometimes in residential settings (e.g. in
therapeutic communities)
Counselling vs psychotherapy
Counselling offers non-judgemental support and encourages the person to clarify and prioritise current problems and to find
solutions. It does not usually explore the therapeutic relationship (as in psychodynamic
psychotherapy).
Counselling tends to help people overcome immediate crises (for example job losses,
bereavement or relationship problems), whereas psychotherapy helps people with more long standing problems of a serious nature.
Psychotherapists thus require a long and specialised training
and continue to receive regular supervision from colleagues about their clinical work
Generally patients who are able to verbalise their problems, are psychologically minded (i.e. able to see that psychological processes could contribute to their problems), and who take some degree of responsibility for the resolution of their difficulties (i.e. are well motivated) make the best candidates.
Assessment for suitability can be difficult, but must be carefully considered, not merely to avoid wasting limited resources, but also to avoid doing harm to the patient (for example by stirring up issues in an exploratory therapy that subsequently cannot then be safely or adequately managed).
Patients with psychosis (other than for some specific CBT interventions) and with serious dependence
on illegal drugs are usually not viewed as suitable.
Patients with strong suicidal ideation can sometimes benefit from psychotherapy, so long as there is an adequate structure provided to enable them to be safely contained during treatment
What is psychodynamic psychotherapy and what does it involve?
Once or twice weekly sessions of usually 50 minutes, which may be brief (from 4 months, to a year) or longer-term
Often a more focused therapy (aiming for circumscribed character and behaviour change)
The therapy centres on the evolution of conscious understanding, primarily by interpreting what the patient does and says during a therapy session and through the inter-subjectivity of the therapeutic
relationship. It thus addresses issues of transference and psychological defence mechanisms.
Therapy sessions are unstructured and the therapist takes a position of benign neutrality, enabling
the patient to freely express things within the safe boundaries of therapy.
The patient’s emotional experience of the therapist being able to tolerate thoughts and feelings previously considered intolerable may also be a significant therapeutic factor.
Such therapies aim for the resolution of unconscious conflict and may not primarily or only be focused on achieving symptomatic change.
An increased understanding of personal problems may initiate symptomatic change, which continues long after termination of formal treatment
When might psychodynamic psychotherapy be suitable?
It is employed in a wide range of disorders, particularly in patients suffering from recurrent and
chronic inter-personal (relationship) difficulties and psychological conflict or alienation.
The presenting problem is understood in the light of past experience (e.g. childhood trauma or deficiency) and the dynamics of the internal world (hence “psychodynamic”).
It can helpfully contribute to the
management of personality disorders, depression, eating disorders and some presentations of anxiety disorders.
What are behavioural therapies and CBT and what does it involve?
These are based on learning theory.
Classical behavioural therapy recognises the role of conditioning
and operant learning.
It uses techniques usually involving some form of exposure to reduce avoidance and permit habituation
It directly addresses the role of dysfunctional thoughts and beliefs in
producing and maintaining undesirable emotional states and behaviours. It is a very structured,
problem-orientated and time-limited therapy (usually requiring between 6 and 15 weekly sessions
each of an hour) aiming for defined symptomatic change. An explicit formulation of the origin and
maintenance of the patient’s problems is developed in collaboration with the patient, and this guides
subsequent therapeutic intervention.
The therapy is very active and the patient will complete
homework tasks (e.g. experimenting with new behaviours, identifying and challenging negative
thoughts, collecting evidence for or against beliefs, etc.) between sessions. CBT also utilises many
behavioural techniques to complement and enhance cognitive approaches.
When might behavioural therapies and CBT be useful
It remains the treatment of choice for simple phobic disorders and for sexual
dysfunctions. Behavioural techniques play a very important role in the treatment of other anxiety
disorders (including panic disorder/agoraphobia, social phobia, obsessional compulsive disorder
(OCD), post-traumatic stress disorder (PTSD), as well as in eating disorders and depression.
There is a developing
evidence base for the use of CBT as part of a comprehensive management package (including
biological treatments) in the management of schizophrenia and bipolar affective disorder.
What is IPT and what does it involve?
This was also initially formulated as a time-limited weekly therapy for depressed patients.
It uses the link between the onset of depressive symptoms and current interpersonal problems as a focus for treatment.
It does not make assumptions about aetiology and does not dwell upon enduring aspects of the personality, but addresses current relationships. Therapists are active and supportive.
Utilisation of IPT
The utilisation of IPT has expanded from depression to other disorders, including eating disorders.
What are family/systemic therapies and what is involved?
These approaches have their roots in anthropology and cybernetics.
They do not view symptoms or
insight as an appropriate focus for treatment intervention, but instead target the system that generates the problematic behaviour.
This is classically seen in a family unit, where each family member is viewed as a component of the system, and the patient’s problem is generated (and maintained) by the system’s malfunctioning.
Systemic therapists might use techniques of suggestion, or emphasising the positive value of symptoms for the whole family, as methods of bringing about
change to the family system.
When is family therapy utilised?
Family therapy is most commonly employed as an intervention for children, but is also used in eating
disorders (particularly with younger anorexic patients) and as an adjunctive treatment in schizophrenia.
What are the principal differences between psychodynamic psychotherapy and cognitive- behavioural psychotherapy?
Cognitive behavioural therapy sees the process of change as being a relatively short-term process whereas psychodynamic therapy is a long term process of change.
Cognitive approach looks at people as conscious logical thinkers, where as the psychodynamic approach focuses on unconscious thoughts.
Cognitive approach looks at information processing and has little focus on emotions. Where as psychodynamic focus on emotional life and childhood experiences.
The aim of psychodynamic therapy is for the client to gain insight and the aim of cognitive behavioural therapy is change.
Psychodynamic therapy is unstructured, CBT is structured
What is “transference”?
Transference is a phenomenon within psychotherapy in which the “feelings, attitudes, or desires” a person had about one thing are subconsciously projected onto the here-and-now
Why is motivation important in assessing a patient’s suitability for psychodynamic psychotherapy?
Positive and lasting results most likely occur when a client becomes actively engaged and personally invested in change
The aim of psychodynamic therapy is for the client to gain insight by exploring unconscious thoughts and focusing on childhood experiences and emotional life and developing their conscious understanding
It is unstructured and guided by patient, primarily by interpreting what the patient does and says during a therapy session and through the inter-subjectivity of the therapeutic relationship.
If patients are unwilling to change and not motivated to explore issues progress will not be made.
They need to be able to verbalise their problems, are psychologically minded (i.e. able to see that psychological processes could contribute to their problems), and who take some degree of responsibility for the resolution of their difficulties
Why do patients in some forms of therapy often get worse before they get better?
Negative therapeutic reaction: self-sabotaging resistance to change, largely unconscious, whereby the patient experiences internal conflict where one part of them wants to change, hence coming to sessions, and another part, the unwell part, is frightened of change and resisting it.
Uncovering un-mourned losses
Revisiting traumatic, upsetting or distressing experiences
Addressing issues of transference and psychological defence mechanisms can make patient experience the emotions they were trying to defend themselves against.
Patients may feel powerless due to exploring the fact they are a product of their early circumstances
Addressing the role of dysfunctional thoughts and beliefs in producing and maintaining undesirable emotional states and behaviours may make patients blame themselves
Patients may revaluate relationships and experiences in a way that leaves them feeling upset
Motivation and engagement required may be tiring for the patient
What specific techniques may be used in CBT?
Cognitive restructuring or reframing
Guided discovery
Exposure therapy
Journaling and thought records
Activity scheduling and behavior activation
Behavioral experiments
Relaxation and stress reduction techniques
Role playing
Successive approximation
Why might some patients be viewed as unsuitable for psychotherapy?
Unable to verbalise their problems (non verbal or incoherent)
Cognitive impairment meaning they are unable to build a relationship with their therapist, follow through the process or comply with sessions
Issues relating to lack of insight, delusions or some kinds of personality disorder
- Not psychologically minded (i.e. able to see that psychological processes could contribute to their problems)
- Not able to take some degree of responsibility for the resolution of their difficulties (i.e. not well motivated).
Which section/form would need to be completed to initiate emergency ECT?
Section 62 of the Mental Health Act – the form is called a C6. This allows two sessions of emergency ECT. A second opinion approved doctor (SOAD) should be applied for at this time in order to provide the required legal framework for ongoing ECT.
ECT and memory loss
Short-term memory loss – this resolves completely in most cases, although memory tests should be performed throughout treatment to monitor for significant memory loss.
Prior to ECT what should be obtained/done?
Informed consent, written information, support from advocate, family member, or friend
Full physical examination
ECG
CXR if indicated
Bloods
Anaesthetic review
How often and for how long is ECT used?
6-12 sessions, twice weekly
Stopped as soon as patient has maximum benefit
Inpatient or outpatient
What is monitored during ECT
Blood pressure
O2 (sats)
ECG leads
EEG (brainwaves, seziure activities)
ECT: eating and drinking
NBM 6 hours prior to treatment
What is given to patient during ECT
General anaesthetic
Suxamethonium (muscle relaxant, prevent full blown seizure activity)
Oxygen
Most common memory impairment due to to ECT?
Anterograde impairments, may persist between and rarely after treatments
How does ECT seizure activity differ from a normal seizure?
Then electrodes placed on scalp passing an electrical charge through brain, inducing generalised therapeutic seizure activity 30-60 secs
Suxamethonium is given as a muscle relaxant - tonic clonic movements very fine and generalised
In what situations is ECT sometimes used and seen to be effective although not advised by guidelines
Routine management of schizophrenia
maintenance therapy
What should be assessed following each ECT session
Mental state
Why are mouthgaurds used in ECT
Cheek or tongue bite
Damage to teeth
Prolonged seziure in ECT
More than 2 mins - seziure aborted
If memory loss is of particular concern in ECT, what can be done?
Administration of ECT can be changed to Unilateral (instead of bilateral) if memory loss is of particular concern.
Place on right hemisphere (non dominant in most patients), one electrode on frontal-temporal region as in bilateral ECT and on top of head
How many ECT sessions are required for most patients with severe depression?
8-10
How long does ECT generally take per patient
one hour (20 min pre covid)
What is meant by MODIFIED ECT
Under GA, this is how it is performed in developed countries
How is ECT regulated
ECTAS - ECT accreditation services
ECT - cautions/contraindications
- Raised intracranial pressure, cerebral aneurysm, recent
cerebrovascular event - MI within 3 months, unstable angina, DVT, K+ imbalance,
uncontrolled HR/BP - Acute respiratory infection, other respiratory conditions
- Recent food/fluids/chewing gum/cigarettes/sweets
- Cochlear implants, Phaeochromocytoma, unstable fractures,
bariatric pts - Pregnancy, controlled epilepsy, pacemakers-not necessarily
contraindicated
Physiological changes during ECT
EEG changes
CVS – initial Parasympathetic followed by sympathetic
stimulation bradycardia followed by a tachycardia. BP would fall and then rise.
Cerebral blood flow (and intracranial pressure) increased
Blood brain barrier may be breached
Hormone changes- TSH, ACTH, Growth Hormone, Prolactin, endorphins, brain derived neurotropic peptides in particular, etc
Potential mechanisms of benefits from ECT
Neurotransmitter hypothesis - balancing chemical changes which have occured during the mental illness, increasing serotonergic and noradrenergic levels in the synapses
Neurophysiological changes
Neuroanatomical changes - particularly increasing dendrites and synapses
Endocrine effects - increased hormone release including cortisol
Neurogenesis - Brain derived neurotrophic factors - increased dendritic and synaptic growth, and synaptic plasticity
Consent for ECT
Has capacity - Consenting:
- Informal (voluntary) patient Obtain informed consent
- Detained (involuntary) patient: Obtain informed consent and complete T4
Has capacity - NOT consenting: Cannot give ECT
Lacks capacity
- Second Opinion Approved Doctor (SOAD) and complete T6
- If emergency complete C6 (Section 62)
- Once patient regains capacity obtain consent
ECTAS monitoring standards
- Pre ECT physical health check
- Consent
- Medication
- Monitoring side effects (memory problems, headache, body aches)
- Hamilton Depression Rating Scale (HDRS) – baseline and after every other treatment, one week and 1-2 months after ECT
- Montreal Cognitive Assessment (MOCA) – baseline, post 2, 6, one week and 1-2 months after ECT.
- ESCORT Nurse
In ECT, what medications does the anaesthetist administer and why?
Etomidate (Etomidate used in Leicester) or Propofol – as GA
Suxamethonium – as a muscle relaxant, as such the seizure induced looks (and is) relatively mild – some patients just show some very mild twitching of their fingers and toes
New neuromodulation techniques
Transcranial Magnetic stimulation (rTMS)
Vagus nerve stimulation (VNS)
What is Projection
Projecting the conflict outside the self
What is sublimation
Attaining the gratification in an acceptable way
What is Reaction Formation?
Doing the opposite of the initial desire
What is splitting?
Separating the conflict as ‘all good’ or ‘all bad’
What is Repression?
Consciously postponing the conflict for later
What is Acting Out
Discharging the anxiety as an outburst
What is introjection?
Acquiring qualities of others as parts of our self
Ego Defence Mechanisms
Projection
Splitting
Suppression
Sublimation
Reaction Formation
Acting out
Introjection
What is projective identification
Projective identification is an unconscious process in which one takes aspects of the self and attibutes them to someone else, who then experiences these feelings
What is meant by internal objects
In essence, the term ‘internal object’ means a mental and emotional image of an external object that has been taken inside the self
What is unconscious phantasy?
Unconscious explanation of things
Influenced by internal objects
dictates emotional responses
What is countertransference?
Countertransference refers to the transference of a therapist’s personal thoughts and feelings onto a client. This can be a problem, but modern psychotherapy recognizes that there are also helpful forms of countertransference.
Countertransference, which occurs when a therapist transfers emotions to a person in therapy, is often a reaction to transference, a phenomenon in which the person in treatment redirects feelings for others onto the therapist.
Principles of attachment theory
•Safety and Security
•Explore and Share
•Emotional bonds
•Part of personality
•Internal Working Model
CBT: cognitive triangle
THOUGHTS:
BEHAVIOUR
EMOTIONS
Becks cognitive triad
Depression - cognitive triangle one way, pathological
CBT: key practice ideas
Socratic questioning
•Formulation
•CBT models of disorder
•Problems and targets/goals
•Collaboration
•Homework
•Making the patient their own therapist
What is a formulation
•Types of formulation:
•5 P’s , biopsychosocial
•Different modes of psychotherapy use formulation with different emphases
•Psychodynamic, CAT, CBT…
•Common themes – to make sense of the problem, to be useful in the work
What is a formulation in CBT for?
Route to understanding the problem
Document - visual representations of problems/parts
Different formats, different uses - longituational, maintenance
Descriptive/explanatory maintainence
Psycho-ed eg level of cognition
Bridge a gap between model/theory and patient experience
Cues towards interventions
•Perhaps predict difficulties in therapy (eg a ‘failure’ to complete home assignments)
What qualities should a formulation have?
•Relevant: does it include the correct problems?
•Coherent: can the patient (and therapist!) understand it? (cf also ‘it’s no wonder that…)
•Useful: can the patient (and therapist!) use it?
•focus on maintenance processes
•Parsimonious: the most for the least
•Dynamic: can be updated and added to
How do we create a formulation
•Talking in session – narrative account
•Drawing out data from ‘recent and specific’ incidences of the problem
•Drawing out data from homework assignments
•Drawing out data from in-session interactions, including difficulties
•By review and updating
•Making use of disorder-specific models, if they fit
•The formulation should fit the patient and their problems, not vice versa!
Socratic questioning
•To clarify thinking and explore the origin of their thinking e.g., ‘Why do you say that?’, ‘Could you explain further?’
•Challenging assumptions e.g., ‘Is this always the case?’, ‘Why do you think that this assumption holds here?’
•Providing evidence as a basis for arguments e.g., ‘Why do you say that?’, ‘Is there reason to doubt this?’
•Discovering alternative viewpoints e.g., ‘What is the counter-argument?’, ‘Can you/anyone see this another way?’
•Exploring implications and consequences e.g., ‘If…happened, what else would result?’, ‘How does…affect…?’
role of socratic questioning in CBT
•Information gathering through guided questioning ‘guided discovery’
•Eliciting information the person already has
•Curious stance over expert stance
•Build alliance: collaboration
•Foster empowerment for the person
•Allows authentic exploration and examination of the problem
CBT: problems and goals
•If this problem were not such a problem, what would you be able to do / do differently?
•SMART where possible – positive not negative in framing
•Enabling sense of measurable
progress, alongside measurement of problem symptom scores eg depression, anxiety, worry, etc
CBT: Collaboration, homework, patient as therapist
•Agenda for sessions
•Collaboration in formulation and at session level
•In session work
•‘Homework’ planning
•Co-created, with meaning
•Review – extract learning, take forward
•Therapy summary and relapse management plan
•Patient explicitly aware of the route they took from A to B, and how to travel that again
Key theory: levels of cognition
Cognitive distortions
•All or nothing
•Over-generalisation
•Selective negative focus
•Disqualifying the positive
•Arbitrary inference
•Magnification or minimisation
•Emotional reasoning
•Should statements
•Labelling and mislabelling
•Personalisation
Cognitive interventions
•Thought diaries and challenging
•Positive data logs
•Continuum work
•Responsibility charts
•Imagery
•Surveys
•Theory A vs Theory B
•Thought challenging
Behavioural interventions
•Exposure
•Diary work
•Nutrition & Energy
•Sleep management
•Behavioural Activation
•Re-establishing Structure
•Ruminating
•Behavioural experiments
CBT: exposure
•A well used aspect in ‘behaviour’ part of CBT
•Relies upon the principle of ‘habituation’ : -
•“the waning of an animal’s behavioural response to a stimulus, as a result of a lack of reinforcement during continual exposure to the stimulus. It is usually considered to be a form of learning involving the elimination of behaviours that are not needed by the animal” (eb.com - Encyclopaedia Britannica)
•We are exposed and habituate every day of our lives!! E.g. new clinic room, new junior doctor, new TV news format, busy train.
•A behavioural route to cognitive shift and emotional/symptom relief
•When used as a treatment technique - looks easy – but needs to be done properly
What is an evidence based treatment for BPD/EUPD
dialectical behavioural therapy - a synthesis or intervention of opposites
thesis + antithesis -> synthesis
What is DBT
Mix of CBT, behaviourism, and mindful practices
Recognising importance of rational and emotional realms of mind
Seeks a mid path between - ‘ Wise mind’
What is distress tolerance
Distress tolerance skills allow a person to survivor an immediate emotional crisis and to accept the reality of the situation when they feel out of control
They help people copte with their feelings when they don’t know exactly what they want or need at that moment
When to use distress tolerance skills
Intense physical/emotional pain
Emotional pain too strong or overwhelming
Strong urges to engage in unskillful behaviour
Need to be productive but are emotionally overwhelmed
DBT: goal of emotional regulation
Naming and understanding our own emotions
Decreases the frequency of unpleasant emotions
Decrease our vulnerability to emotions
Decrease emotional suffering
Interpersonal effectiveness
Learning to get along with others whilst also asserting your own needs is essentiel to healthy relationships
CBT indications
CBT is recommended in NICE guidelines for many different problems, including:
anxiety disorders (including panic attacks)
depression
obsessive compulsive disorder (OCD)
post-traumatic stress disorder (PTSD)
psychosis and schizophrenia
bipolar disorder
eating disorders
tinnitus
insomnia
There is also good evidence that CBT is helpful in helping people cope with the symptoms of many other conditions, including:
chronic fatigue syndrome (CFS)
irritable bowel syndrome (IBS)
fibromyalgia
chronic pain
How is CBT delivered
CBT:
- individual sessions with a therapist or as part of a group
- 5-20 sessions ~ I hour each
- Most sessions begin with mutual agenda setting
- concerned on how patient is thinking and acting themselves
- Patients encouraged to work on pre-planned tasks together between sessions
- as the therapy comes to an end therapist + patient think together about how to
continue using CBT techniques in daily life after treatment.
Circumstances in which cognitive– behavioural therapy is indicated
The patient prefers to use psychological interventions, either alone or in addition to medication
The target problems for CBT (extreme, un- helpful thinking; reduced activity; avoidant or unhelpful behaviours) are present
No improvement or only partial improvement has occurred on medication
Side-effects prevent a sufficient dose of medication from being taken over an adequate period
Significant psychosocial problems (e.g. relation- ship problems, difficulties at work or un- helpful behaviours such as self-cutting or alcohol misuse) are present that will not be adequately addressed by medication alone
Target problems for CBT
Extreme of unhelpful thinking
Reduced activity
Avoidant or unhelpful behaviours
What does CBT involve?
They provide: a focus on current problems of relevance to the patient; a clear underlying model, structure or plan to the treatment being offered; and delivery that is built on an effective relationship with the practitioner.
CBT is founded on these principles and is essentially a psycho- educational form of psychotherapy.
Its purpose is for patients to learn new skills of self-management that they will then put into practice in everyday life.
It adopts a collaborative stance that encourages patients to work on changing how they feel by putting into practice what they have learned.
Unhelpful thinking styles: People with depressed and anxious thinking tend to show certain common characteristics
They overlook their strengths, become very self-
critical and have a bias against themselves,
thinking that they cannot tackle difficulties They unhelpfully dwell on past, current or future problems; they put a negative slant on things, using a negative mental filter that focuses only on their difficulties and
failures
They have a gloomy view of the future and get
things out of proportion; they make negative predictions about how things will work out and jump to the very worst conclusion (catastrophise) that things have gone or will go very badly wrong
They mind-read and second-guess that others think badly of them, rarely checking whether this is true
They unfairly feel responsible if things do not turn out well (bearing all responsibility) and take things to heart
They make extreme statements and have unhelpfully high standards that are almost impossible to meet; they hold rules such as ‘I should/must/ought/have got to …’.
Overall, thinking becomes extreme, unhelpful and out of proportion
CBT- five areas model
1 - life situation, relationships and practical problems
2 - altered thinking
3 - altered emotions
4- altered physical feelings/ symptoms
5 - altered behaviour/activity levels
Summary of range of problems and difficulties experienced by anxiety and depression
Issues relating to life situations/relationships, and practical problems
• Debts, housing or other difficulties
• Problems in relationships with family, friends,
colleagues, etc.
• Life events such as deaths, redundancy,
divorce, court appearance.
Examples of mood states that may be described by patients
t
• Low mood, depression, sadness, feeling ‘blue’, ‘down’, ‘fed-up’, ‘hacked off’
• Feeling flat or numb, or with no capacity for enjoyment or pleasure
• Anxiety, worry, stress, fear, panic, ‘hassled’
• Guilt
• Angry or irritable
• Shame or embarrassment.
Depression vs anxiety - altered emotions
Depression:
• Altered sleep (waking earlier than usual,
difficulty getting to sleep, disrupted sleep
pattern)
• Altered appetite (increased or decreased)
• Altered weight (increased or decreased)
• Reduced concentration and memory deficits
• Reduced energy, tiredness, lethargy
• Reduced sex drive
• Constipation
• Pains, physical agitation/restlessness.
Anxiety:
• Restlessness and inability to relax
• Awareness of physical tension in their muscles,
with aches, pains or tremors (‘tense, wound-up’)
• Shakiness or unsteadiness on their feet
• A feeling of being physically drained and
exhausted
•
• • •
• •
Feeling sick, with a churning stomach, ‘butterflies’, reduced appetite
Finding it difficult getting off to sleep
Feeling hot, cold, sweaty or clammy Awareness of a racing heart and/or over- breathing, with rapid, gasping breaths Awareness of a muzzy-headed (depersonal- ised) feeling
Pins and needles/tingling sensations/tight chest.6
Identifying reduced activity in depression
Has the person begun to:
• Stop meeting friends?
• Reduce socialising/going out/joining in with
others?
• Reduce hobbies/interests?
• Reduce pleasurable things in life?
• Find that life is becoming emptier?
• Reduce activities of daily living (self-care,
housework, eating, etc.)?
Idefntigying areas of avoidance in anxiety
The question to ask is ‘What things have you stopped doing since you started feeling anxious?’
Checklist
• Are there situations, people or places that they are avoiding?
• Is there anywhere they cannot go or anything they cannot do because of their anxiety?
• What would they be able to do if they were not feeling anxious?
Identifying unhelpful behaviours
A useful question to help identify unhelpful behaviours is ‘What things have you started doing to cope with your feelings of anxiety and/or depression?’
Checklist
Are they:
• Seeking reassurance?
• Only going out/going to certain places
when accompanied by other people (safety behaviour)?
• Misusing alcohol or illegal drugs?
• Misusing medication?
• Withdrawing from others?
• Actively pushing others away?
• Comfort-eating?
• Harming themselves in some way as a means
of blocking how they feel?
Which type of psychotherapy encompasses therapy of an analytical nature; essentially it is a form of depth psychology that focuses on the unconscious and past experiences, to determine current behaviour?
Psychodynamic psychotherapy
Psychodynamic therapy vs psychoanalysis
Psychodynamic therapy tends to be less intensive and briefer than psychoanalysis, and also relies more on the interpersonal relationship between patient and therapist than do other forms of depth psychology. It is a focus that has been used in individual psychotherapy, group psychotherapy, family therapy, and to understand and work with institutional and organisational contexts.
What is psychoanalysis
Regular sessions of psychoanalysis provide a setting where unconscious patterns can be brought into awareness with a view to changing them. The patient’s relationship with the analyst is an important influence upon the patient’s unconscious ways of behaving and, in itself, becomes a central area of focus, highlighting the patient’s patterns within the relationship in the immediacy of the sessions.
Patient factors to consider when selecting a psychotherapy
Presenting problem (detail and associated behavioural responses, thoughts and feelings.)
Solutions/treatment already tried
Background history
Current circumstances
Mental state examination
Attitude to treatment (One needs to explore patients’ abilities to recognise some responsibility for their problems and their willingness to work actively towards finding solutions. If one of the more sophisticated therapies is being considered, one also needs to explore whether the patient can make use of psycho- logical insight and has the capacity (and willing- ness) to enter into an intensive treatment relationship)
Family/couple dynamic
Aspects of problem formulation
Behavioural Cognitive Dynamic
Sy temic
Principles of treatment planning
Least necessary intervention Collaborative process
Based on formulation
Meet (& treat?) family Provisional treatment contract
DBT
The therapy includes weekly individual sessions and weekly life-skills group
sessions that teach skills in 4 domains: mindfulness, distress tolerance, regulation of
emotions and interpersonal effectiveness. The therapy is designed to last at least 1 year.
Antidepressant therapy in ECT
Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment
The recommended regime is to safely reduce them to the minimum dose. You may actually add an increased dose of antidepressant towards the end of the ECT cours
What type of amnesia might ECT cause
Retrograde amnesia (remembering events prior to the insult) is far more common that anterograde amnesia (loss of ability to form new memories after the insult)
What is displacement
Displacing feelings - angry at person A due to something person B has done
