still to come Flashcards

Question

What is the definition of specific (isolated) phobia:

Answer 1

A fear restricted to a specific object or situation (excluding agoraphobia and social phobia).

Answer 2

Agoraphobia Maintained by avoidance which prevents deconditioning and sets up a vicious cycle of anxiety. Social phobia Uncertain aetiology. Usually begins in late adolescence, an age at which people are concerned about the impression they make on others. Specific phobia Conditioning event in early life, i.e. a frightening experience. Possibly a role for learned behaviour, e.g. from parents

Answer 3

Agoraphobia - 25-30 years, 2:1 male to female ration Social phobia - Adolescence - 1:1 Specific phobia - Childhood but can develop later in life- 1:1

Answer 4

Aversive experiences (prior experiences with specific objects or situations) Stress and negative life events Other anxiety disorders Mood disorders Substance misuse disorders Family history

Answer 5

Tachycardia is the usual autonomic response, however in phobias of blood, injection and injury, a vasovagal response (bradycardia) is produced, commonly leading to fainting (syncope)

Answer 6

Include unpleasant anticipatory anxiety, inability to relax, urge to avoid the feared situation and, at extremes, a fear of dying

Answer 7

panic disorder. Indeed the ICD-10 divides agoraphobia into: agoraphobia with panic disorder and agoraphobia without panic disorder.

Answer 8

A. Marked and consistently manifest fear in, or avoidance of, at least two of the following: 1. Crowds 2. Public spaces 3. Travelling alone 4. Travelling away from home B. Symptoms of anxiety in the feared situation with at least two symptoms present together (and at least one symptom of autonomic arousal). C. Significant emotional distress due to the avoidance, or anxiety symptoms. Recognized as excessive or unreasonable. D. Symptoms restricted to (or predominate in) feared situation.

Answer 9

A. Marked fear (or marked avoidance) of being the focus of attention, or fear of acting in a way that will be embarrassing or humiliating. B. At least two symptoms of anxiety in the feared situation plus one of the following: 1. Blushing 2. Fear of vomiting 3. Urgency or fear of micturition/defecation C. Significant emotional distress due to the avoidance or anxiety symptoms. D. Recognized as excessive or unreasonable. E. Symptoms restricted to (or predominate in) feared situation.

Answer 10

A. Marked fear (or avoidance) of a specific object or situation that is not agoraphobia or social phobia B. Symptoms of anxiety in the feared situation. C. Significant emotional distress due to the avoidance or anxiety symptoms. Recognized as excessive or unreasonable. D. Symptoms restricted to the feared situation.

Answer 11

‘What situations cause you anxiety or embarrassment?’ (specific phobia) ‘Do you get symptoms in situations from which escape would be difficult?’, ‘Do you get symptoms in places or situations where help may not be available?’, ‘Do you get symptoms while being in a crowd or travelling on public transport?’ (agoraphobia) ‘Do you ever worry about what people think of you? Does this worry ever lead to you avoiding certain situations?’ (social phobia) ‘Do you avoid any situation because you know you will feel panicky?’ (anticipatory anxiety)

Answer 12

1. Anxiety occurs in Specific Situations: Agoraphobia – Public transport, supermarkets (especially waiting in queues), cinemas, empty streets. Social phobia – Social gatherings, parties, public speaking, meetings, classrooms, eating in public. 2. There is Anticipatory Anxiety when there is a prospect of encountering the feared situation. 3. There is Attempted Avoidance of circumstances that precipitate anxiety.

Answer 13

ppearance & Behaviour Restless and wanting to escape. Pale, sweaty, hyperventilating. May lose consciousness (blood or injection phobia). Speech May be trembling or they may become speechless. Mood Anxious. Thought Unpleasant feelings towards threat. Fear of situation. Desire to escape. Fear of dying. Insight Poor when feared stimulus present. Good when separated from stimulus.

Answer 14

As symptoms occur in a defined situation, diagnosis is usually straightforward with minimal need for investigations. Questionnaires include the Social Phobia Inventory and Liebowitz Social Anxiety Scale.

Answer 15

Psychiatric: Panic disorder, PTSD, anxious personality disorder, somatoform disorders, adjustment disorder, depression, schizophrenia (may avoid socializing because of paranoid delusions).

Answer 16

Try to establish a good rapport with the patient. Remember, particularly with social phobia, it may have been very challenging for the patient to attend the appointment. Advise avoidance of anxiety-inducing substances, e.g. caffeine. Screen for significant co-morbidities such as substance misuse and personality disorders. Refer to a specialist if there is a risk of self-harm, suicide, self-neglect or significant co-morbidity

Answer 17

CBT is the psychological intervention of choice. The behavioural component includes graduated exposure and desensitization. Graduated exposure techniques such as walking increased distances from home day by day, can be used. SSRIs are the first-line pharmacological agent.

Answer 18

CBT (individual or group) specifically designed for social phobia. Graduated exposure to feared situations is included both within treatment sessions and as homework. Pharmacological interventions include SSRIs (escitalopram or sertraline), SNRIs (venlafaxine) or if no response to these, a MAOI (moclobemide). Psychodynamic psychotherapy for those who decline CBT or medication.

Answer 19

The mainstay of treatment is exposure either using self-help methods or more formally through CBT. Benzodiazepines may be used as anxiolytics in the short term (due to risk of dependence) for instance if a patient needs an urgent CT scan and they are claustrophobic.

Answer 20

Panic disorder is characterized by recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.

Answer 21

Biological- Genetics: Along with OCD, it is one of the most heritable anxiety disorders. Neurochemical: Post synaptic hypersensitivity to serotonin and adrenaline. Sympathetic nervous system (SNS): Fear or worry stimulates the SNS → ↑cardiac output which can lead to further anxiety. Cognitive- Misinterpretation of somatic symptoms (e.g. fear that palpitations will lead to a heart attack). Environmental- Presence of life stressors can lead to panic disorder.

Answer 22

Panic disorder has a prevalence of 1% in the general population. It is three times more common in ♀. The usual age of onset is late adolescence.

Answer 23

Family history Major life events Age (20–30) Recent trauma Females Other mental disorders White ethnicity Asthma Cigarette smoking Medication

Answer 24

A. Recurrent panic attacks that are not consistently associated with a specific situation or object, and often occur spontaneously. The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations. B. Characterized by ALL of the following: (1) Discrete episode of intense fear or discomfort; (2) Starts abruptly; (3) Reaches a crescendo within a few minutes and lasts at least some minutes; (4) At least one symptom of autonomic arousal: palpitations, sweating, shaking/tremor, dry mouth; (5) Other symptoms`

Answer 25

Panic symptoms usually peak within 10 minutes and rarely persist beyond an hour

Answer 26

PANICS Disorder Palpitations, Abdominal distress, Numbness/Nausea, Intense fear of death, Choking feeling/Chest pain, Sweating/Shaking/Shortness of breath, Depersonalization/Derealization

Answer 27

‘Are you generally anxious or are there periods where you are anxiety-free?’ (episodic) ‘Can you predict when these attacks will come on?’ (unpredictable) ‘Have you ever been so frightened that you felt your heart was pounding and that you might die?’ (intense fear and anxiety) ‘Are you worried about your health or any other specific things?’ (major life stressors)

Answer 28

Same as GAD Appearance and behaviour Face looks worried with brow furrowed. Restless with tremor. Sweaty when you shake their hand. Hyperventilating. Lip biting. Pallor. Tense posture. Speech Trembling. Slow rate. Mood Anxious. Thought Repetitive worrying thoughts. Thoughts may concern personal health, safety of others or excessive worry about everyday events, e.g. relationships, finances. Perception No hallucinations. Cognition May complain of poor memory and reduced attention/concentration. Insight May or may not have insight.

Answer 29

Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia). ECG: may show sinus tachycardia. Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and Depression Scale.

Answer 30

Psychiatric: Other anxiety disorders (e.g. generalized anxiety disorder, phobic anxiety disorder), dissociative disorder, bipolar affective disorder, depression, schizophrenia, adjustment disorder. Organic: Phaeochromocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrhythmias, alcohol/substance withdrawal

Answer 31

Age of onset: Variable: adolescence to late adulthood When it occurs: Persistent Assosciated behaviour: Agitation Cognition: Constant worry Associations: Depression

Answer 32

Age of onset : Late adolescence to early adulthood When it occurs: Episodic Assosciated behaviour: Escape Cognition: Fear of symptoms Associations: Depression, agoraphobia, substance misuse

Answer 33

Age of onset: Childhood to late adolescence When it occurs: Situational Associated behaviour: Avoidance Cognition: Fear of situation Associations: Substance misuese

Answer 34

SSRIs are first-line but if they are not suitable, or there is no improvement after 12 weeks, then a TCA, e.g. imipramine or clomipramine may be considered. Benzodiazepines should not be prescribed. CBT is the psychological intervention of choice, focusing on recognition of panic triggers. Self-help methods include bibliotherapy (giving written information on panic disorder and how to overcome it), support groups and encouraging exercise to promote good health.

Answer 35

Step 1: Recognition and diagnosis Step 2: Treatment in primary care Step 3: Review and consideration of alternative treatments Step 4: Review and referral to specialist mental health services Step 5: Care in specialist mental health services

Answer 36

Is an intense, prolonged, delayed reaction following exposure to an exceptionally traumatic event.

Answer 37

Normal bereavement goes through a number of stages in response to loss of a loved one. Abnormal bereavement has a delayed onset, is more intense and prolonged (>6 months). The impact of their loss overwhelms the individual’s coping capacity.

Answer 38

An abnormal reaction to sudden stressful events

Answer 39

Normal adjustment refers to psychological reactions involved in adapting to new circumstances. Adjustment disorder is when there is significant distress (greater than expected), accompanied by an impairment in social functioning

Answer 40

Severe assault (e.g. physical or sexual abuse, robbery, mugging). Major natural disaster (e.g. earthquakes, floods). Serious road traffic accident. Observer/survivor of civilian disaster (e.g. acts of terrorism, the Holocaust). Involvement in wars (e.g. World War II, Vietnam War). Freak occurrences (e.g. near drowning when on holiday). Physical torture. Prisoner of war or hostage situation. Hearing about unexpected injury or violent death of a family member or friend.

Answer 41

Exposure to a major traumatic event: Professions at risk (armed forces, police, fire services, journalists, doctors), groups at risk (refugees, asylum seekers). Pre-trauma: Previous trauma, history of mental illness, females, low socioeconomic background, childhood abuse. Peri-trauma: Severity of trauma, perceived threat to life, adverse emotional reaction during or immediately after event. Post-trauma: Concurrent life stressors, absence of social support.

Answer 42

Approximately 3% of adults in England suffer from PTSD. 25–30% of individuals experiencing a traumatic event may go on to develop PTSD. It can affect people of all ages, but is more common in ♀ (♀:♂ ratio is 2:1).

Answer 43

PTSD symptoms must occur within 6 months of the event and can be divided into four categories: 1. Reliving the situation (persistent, intrusive, involuntary): Flashbacks, vivid memories, nightmares, distress when exposed to similar circumstances as the stressor. 2. Avoidance: Avoiding reminders of trauma (e.g. associated people or locations), excessive rumination about the trauma, inability to recall aspects of the trauma. 3. Hyperarousal: Irritability or outbursts, difficulty with concentration, difficulty with sleep, hypervigilance, exaggerated startle response. 4. Emotional numbing: Negative thoughts about oneself, difficulty experiencing emotions, feeling of detachment from others, giving up previously enjoyed activities.

Answer 44

A. Exposure to a stressful event or situation of extremely threatening or catastrophic nature (would likely cause distress in almost anyone). B. Persistent remembering (‘reliving’) of the stressful situation. C. Actual or preferred avoidance of similar situations resembling or associated with the stressor. D. Either (1) or (2) 1. Inability to recall some important aspects of the period of exposure to the stressor. 2. Persistent symptoms of increased psychological sensitivity and arousal. E. Criteria B, C & D all occur within 6 months of the stressful event, or the end of a period of stress.

Answer 45

‘Has there been any traumatic incident or event in your life recently which may account for how you are feeling?’ (exposure to stressful event) ‘Do you ever get any flashbacks, vivid memories or nightmares about the events that took place?’ (reliving the situation) ‘Do you find yourself constantly thinking about the same thing?’ (rumination) ‘Have you had any problems with sleep since the event?’, ‘Are you feeling more irritable or having trouble concentrating?’, ‘Do you get startled easily?’ (hyperarousal)

Answer 46

Denial Anger Bargaining Depression Acceptance

Answer 47

Appearance & Behaviour Hypervigilance (‘on edge’), exaggerated startle reaction, may have features of anxiety or depression, e.g. poor eye contact. Speech Slow rate. Trembling. Non-spontaneous. Mood Anxious. Thought Pessimistic. Reliving or remembering of the event. Perception No hallucinations. May have illusions. Cognition Poor attention and concentration. Insight Good.

Answer 48

Questionnaires: Trauma Screening Questionnaire (TSQ), Post-traumatic diagnostic scale. CT head: if head injury suspected.

Answer 49

Psychiatric: Adjustment disorder, acute stress reaction, bereavement, dissociative disorder, mood or anxiety disorders, personality disorder. Organic: Head injury (result of traumatic event), alcohol/substance misuse.

Answer 50

Exposure to an exceptional physical or mental stressor (e.g. physical assault, road traffic accident) followed by an immediate onset of symptoms (within one hour). Divided into mild, moderate or severe based on extent of symptoms`

Answer 51

anxiety symptoms (see Section 5.2, GAD), narrowing of attention, apparent disorientation, anger or verbal aggression, despair or hopelessness, uncontrollable or excessive grief. Symptoms must begin to diminish within 8 hours (for transient stressors) or 48 hours (for continued stressors)

Answer 52

Identifiable (non-catastrophic) psychosocial stressor (e.g. redundancy, divorce) within one month of onset of symptoms. Symptoms are variable but can be of the types found in the affective disorders or the neurotic disorders (but not severe enough to be classed as a specific psychiatric disorder). The symptoms must be present for less than 6 months.

Answer 53

Watchful waiting may be used for mild symptoms lasting <4 weeks. Military personnel have access to treatment provided by the armed forces. Trauma-focused CBT should be given at least once a week for 8–12 sessions. Short-term drug treatment may be considered in the acute phase for management of sleep disturbance (e.g. zopiclone). Risk assessment is important to assess risk for neglect or suicide

Answer 54

All sufferers should be offered a course of trauma-focused psychological intervention. The two options for psychological intervention are CBT and eye movement desensitization and reprocessing (EMDR). The goal of EMDR is to reduce distress in the shortest period of time. It is a form of psychotherapy, with one technique involving eye movements to help the brain process traumatic events (see Section 12.1, Psychotherapies). Drug treatment should be considered when: (1) little benefit from psychological therapy; (2) patient preference not to engage in psychological therapy; (3) co-morbid depression or severe hyperarousal which would benefit from psychological interventions. Paroxetine, mirtazapine, amitriptyline and phenelzine are licensed for treatment of PTSD in the UK. Evidence for paroxetine is weaker than the other three drugs. Practically, amitriptyline and phenelzine are rarely used as a result of their side effects and tolerability.

Answer 55

is characterized by recurrent obsessional thoughts or compulsive acts, or commonly both. It is ranked by the WHO as one of the top ten most disabling illnesses in terms of impact upon quality of life.

Answer 56

Unwanted intrusive thoughts, images or urges that repeatedly enter the individual’s mind. They are distressing for the individual who attempts to resist them and recognizes them as absurd (egodystonic) and a product of their own mind.

Answer 57

Repetitive, stereotyped behaviours or mental acts that a person feels driven into performing. They are overt (observable by others) or covert (mental acts not observable).

Answer 58

Psychoanalytic: Filling the mind with obsessional thoughts in order to prevent undesirable ideas from entering consciousness. Behavioural: Compulsive behaviour is learned and maintained by operant conditioning. The anxiety created by the obsession is reduced by performing the compulsion, and subsequently the need to perform the compulsion is increased.

Answer 59

Related to ↓ serotonin and abnormalities of the frontal cortex and basal ganglia. Twin and family studies suggest a genetic contribution to OCD particularly with paediatric onset. Childhood group A beta-haemolytic streptococcal infection may have a role in causing OCD symptoms by setting up an autoimmune reaction which damages the basal ganglia (this is called PANDAS)

Answer 60

depression (30%), schizophrenia (3%), Sydenham’s chorea, Tourette’s syndrome and anorexia nervosa.

Answer 61

A. Either obsessions or compulsions (or both) present on most days for a period of at least 2 weeks. B. Obsessions (thoughts, ideas or images) or compulsions (acts) share a number of features (see Clinical features), ALL of which must be present. C. The obsessions or compulsions cause distress

Answer 62

The prevalence of OCD ranges from 0.8–3%. It is most common in early adulthood and is equally common in ♂ and ♀. OCD is more common in the relatives of OCD patients than it is in the general population. Carrying out the compulsive act (e.g. washing) is likely to exacerbate the obsession and is thus a maintaining factor. Developmental factors such as neglect, abuse, bullying and social isolation may have a role

Answer 63

Contamination (most common) Fear of harm Excessive concern with order or symmetry Sex, violence, blasphemy, doubt

Answer 64

Checking (most common)- gas taps, water taps, doors Cleaning, washing Repeating acts Mental compulsion Hoarding

Answer 65

FORD car 1. Failure to resist: At least one obsession or compulsion is present which is unsuccessfully resisted. 2. Originate from patient’s mind: Acknowledged that the obsessions or compulsions originate from their own mind, and are not imposed by outside persons or influences. 3. Repetitive and Distressing: At least one obsession or compulsion must be present which is acknowledged by the patient as excessive or unreasonable. 4. Carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but reduces anxiety levels.

Answer 66

1. Obsession 2. Anxiety 3. Compulsion 4. Relief

Answer 67

‘Do you have any distressing thoughts that enter your mind despite trying hard to resist them?’, ‘Is there any unwanted thought that keeps bothering you that you would like to get rid of but cannot?’ (obsessions) ‘Do you worry about contamination with dirt even after washing?’, ‘Do you repeatedly check things you have already done?’, ‘Do you find yourself having to touch, count and arrange things many times?’, ‘Do you wash or clean a lot? Do you check things a lot?’, ‘Are you concerned about putting things in a specific order, or do you get upset by not completing tasks?’ (compulsions) ‘Do your daily activities take a long time to finish?’ (due to carrying out compulsions)

Answer 68

Patient may be on edge (easily startled). May look visibly worried or lost in thought. May be constantly checking doors or fidgety with hands (as they can’t wash them). 112 May demonstrate increasing levels of anxiety if unable to succumb to compulsion (Fig. 5.6.2). Thoughts are unwanted, intrusive and uncomfortable for the patient. Obsessions can be distracting and lead to poor concentration. Insight is usually very good (as they recognize the thoughts are a product of their own mind).

Answer 69

Yale–Brown obsessive–compulsive scale (Y-BOCS) → 10-item questionnaire with each item graded from 0–4; e.g. Time occupied by obsessive thoughts (0 = none, 4 = extreme, >8 hours/day).

Answer 70

Anorexia + Bulimia Body dysmorphic disorder Anxiety Depressive Hypochondrial disorder Schizophrenia Tourettes Kleptomania Dementia Epilepsy

Answer 71

1. CBT (including ERP – exposure and response prevention) ERP is a technique in which patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the repetitive actions which lessen that anxiety (e.g. washing their hands). After initial anxiety on exposure, the levels of anxiety gradually decrease. 113 2. Pharmacological therapy SSRIs are the drug of choice in OCD. NICE recommends fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram. Clomipramine is an alternative drug therapy. This can be combined with citalopram in more severe cases. Alternatively, an antipsychotic can be added in with an SSRI or clomipramine

Answer 72

Psychoeducation, distracting techniques and self-help books can be used. Any potential suicide risk should be identified and managed. Co-morbid depression should be identified and treated. Method of treatment depends upon the degree of functional impairment (Fig. 5.6.3). This ranges from mild (limited impact on ADL) to severe (obsessional slowness that greatly impacts performance).

Answer 73

Cover two bases Becton Centre( below) And Centenary House (above) Also STAR team is based in the Children's Hospital

Answer 74

At Centenary House: SEDATT – Eating Disorders Service Forensic CAMHS Children’s Looked After service Learning Disabilities Becton Centre Learning Disabilities Inpatient – Ruby Lodge Adolescent Inpatient – Sapphire Lodge Children's Inpatient unit – Emerald Lodge Young Children's Day Patient – Amber Lodge

Answer 75

Duty team Community intensive team Supportive treatment and recovery

Answer 76

1st year of life: Loud noises, strangers, new places, heights Preschool 2-6: Being alone, darkness, animals, imaginary creatures School age 4-10: Fears of negative evaluation by others, illness/bodily injury, supernatural phenomenon, natural disaster

Answer 77

Diagnosis requires a persistence in behaviours for at least a four week period for children and young people. Developmentally inappropriate, visible distress linked to becoming separated from a primary care giver, which leads to pronounced stress and agitation (unable to settle). Older children/adolescents – excessively worry about harm coming to a primary care giver, again leading to pronounced stress and agitation. All ages express considerable reluctance/refusal to leave the primary care giver at any time, including bedtimes and may also have nightmares linked to this anxiety. Most common anxiety disorder under 10 years Older children/adolescents – excessively worry about harm coming to a primary care giver, again leading to pronounced stress and agitation. All ages express considerable reluctance/refusal to leave the primary care giver at any time, including bedtimes and may also have nightmares linked to this anxiety. Most common anxiety disorder under 10 years

Answer 78

Significant Anxiety symptoms Fear of a specific aspect of school Avoidance

Answer 79

Diagnosis requires symptoms to be present for a period of at least six months and must be occurring most days. Selective Mutism is related to Social Anxiety Disorder. Children experience difficulty or inability to speak in social contexts or situations

Answer 80

How long has this been affecting Emma? Why? Reason for not taking medication/ going to GP Symptoms eg palpitations, nausea, fear of choking etc Other anxieties eg separation, school phobia, GAD Other related conditions eg depression, self harm Family History

Answer 81

Psychoeducation Relaxation Systematic desensitisation CBT

Answer 82

When we have an intense physiological response to a situation or object that we qualify as harmful or dangerous, our brain starts activating certain regions. One of them is the amygdala, which has been said to intervene in emotional responses such as fear and anxiety. In a none anxious child/young person, the Prefrontal cortex inhibits the Amygdala. The Amygdala is the brain structure that is always on the lookout for threats so it can quickly react and keep us safe. Flight, Fright, Freeze

Answer 83

In a anxious child/young person, the Amygdala is hypersensitive and the connections with the Prefrontal Cortex become weaker. With anxiety the Amygdala generates too many false alarms such as; perceiving a safe situation as threatening. Anxiety causes great stress and stress shrinks the Hippocampus. This region of the brain is our memory store. When anxious our accessible memories become limited and only those linked to failure, threat or danger are drawn upon, memories of success, certainty and safety become inaccessible.

Answer 84

Academic pressure; Being asked to provide an answer (fear of failure, answer not known) Social pressure; Play times (not knowing how to interact with peers, start a conversation or give the wrong answer and be mocked/bullied. Separation anxiety; Will my mum or dad come back? (fearful of being left alone) Developmental or following trauma such as a bereavement. Health related issues; Will I or someone be sick today? (not wanting to eat, go to public places) Confusing physical anxiety symptoms with illness (impending doom feeling) Crossing a road; The sound of a car triggers a child to panic and run. (Thinking that they may get run over) Family Dynamics; Parental separation, illness, DV/Substance misuse (How will mum or dad be today?)

Answer 85

Hyperthyroidism Arrhythmias Epilepsy – Prodromal symptom Phaeochromocytoma Asthma Illicit Drugs – speed, cocaine, Caffeine - coffee

Answer 86

Assessment – checking for co-morbidities ( e.g.ASD) Anxiety management techniques Graded exposure CBT Medication Group Work

Answer 87

Take a deep breath into your belly and slowly breath out Pick a colour and take a look around the space you are in, can you see it? If your mind wanders, gently tell yourself and bring it back to your breath and colour search

Answer 88

Clasp your hands together Squeeze them as tight as you can while trying to pull them apart Hold the tension between your hands like this for 7 seconds Relax and allow your hands and arms to go floppy Now focus on how your hands and arms now feel

Answer 89

Music (“Have you got your headphones?) Item to distract (attachment – soft toys, fidget spinners, stress ball, resistance bands, mindfulness colouring books, spiral bobbles) Worry space, corner, box or journal Positive statement cards Bubble blowing

Answer 90

. Identify/notice it 2. Challenge it 3. Re-write it 4. Distract 5. Change behaviour