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
CBT: cognitive triangle
THOUGHTS:
BEHAVIOUR
EMOTIONS
Becks cognitive triad
Depression - cognitive triangle one way, pathological
Key theory: levels of cognition
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’
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
