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Flashcards in Physical/psychological treatments Deck (24):

How does ECT work?

Neurochemical theories: Chanes in receptor expression of D2 and 5-HT2 receptors

Neuroendocrine theories: Restores diurnal rhythm of HPA axis, plus enhances production + release of several neuroendocrine substances (e.g. oxytocin)

Neuro + synaptogenesis: Increase in BDNF and synaptic remodelling seen in animal data

Connectivity: Changes in connectivity between dorsolateral prefrontal cortex and subgeniculate cortex



Indications for ECT

Severe depression: Stupor, life-threatening, treatment-refractory

Moderate depression: Prolonged, resistant to multiple drugs + psychotherapy

Mania + psychosis: Prolonged/severe



Physiological effects of ECT

Raised pressures: Intraocular, intragastric, hypertension

Dental: Supraphysiological bite

Cardiac: Emergent arrhythmias

Endocrine: ACTH, cortisol, glucagon release --> may affect blood sugar


Efficacy of ECT

High remission rates, but short-lived (approx 2w) --> need to include supplemental management after course of CBT

90-95% for puerperal psychosis

80-85% for unipolar depression

80% catatonia

70-75% bipolar


Side effects of ECT

  • Immediate:
    • Headache
    • Nausea
    • Muscle ache
    • Confusion/disorientation
  • Longer-term
    • Antero- + retrograde amnesia for duration of treatment + following month
    • Deficits in autobiographical memory up to 6mo before treatment (RARER, 15-20%)
  • Rare but severe:
    • Emergent hypomania
    • Bone/dental/jaw injury


Length of ECT treatment

Twice a week, usually for 6-12 sessions (3-6w)


Consent and capacity frameworks for ECT


  • Capacitous --> need consent
  • Lacks capacity --> need assent


  • Capacitous --> need consent (c.f. pharma treatments)
  • Lacks capacity --> needs SOAD (no 3-month rule)


Contraindications for ECT

No absolutes, but several cautions

Cerebral: Raised ICP, cerebral haemmorhage, stroke, aneurysm, glaucoma/raised IOP

Cardiac: Recent MI, arrhythmia, phaeochromocytoma, malignant hypertension

Unstable COPD/chest infexion



Principles of rTMS

Repetitive transcranial magnetic stimulation

Pulses of strong magnetic field applied to excite/inhibit cortical pyramidal cells in a more localised fashion compared to ECT (esp dorsolateral prefrontal cortex)


Timecourse of rTMS treatment

45-min sessions (may be optimised with shorter, theta-burst rTMS)

5x per week

For 4-6 weeks

Presents logistical barrier


Efficacy of rTMS

For treatment-resistant depression: 1:1:1 recovery/partial recovery/no effect


Side effects of rTMS

Headache, facial discomfort

Syncope occasionally

Rarely seizure induction


Contraindications for rTMS

Epilepsy, stroke, brain tumour


Three levels of cognition in CBT model

Automatic thoughts: Rapid images/verbal interpretations of events --> often taken as true although not necessarily correct

Dysfunctional assumptions: 'Rules' for behaving and interacting with world

Core beliefs: Absolute statements about self, others, world that shape how we view the world

These are explored in the formulation of CBT


Common negative cognitive biases

All-or-nothing thinking



Disqualifying positives/focusing on negatives

Labeling/jumping to conclusions



Rationale behind CBT

Cognition, emotion, behaviour, and physical sensations co-exist and influence each other

Influencing cognition/learned behaviorus --> influence on emotions/physical sensations leading to improvement


Principles/tools of CBT

  1. Thought diaries: Allow breakdown of unhelpful thinking patterns + identification of trends/core beliefs
  2. Socratic questioning: Challenging cognition w/ support of therapist as collaborator (not as expert) --> pt reaches own conclusions
  3. Behavioural experiments: Desensitisation by breaking link between thought and conclusion


Stepped care model for psychological treatment

Step 1: Assessment, psychoeducation, monitoring, possible referral to IAPT (i.e. Talking Space for steps 2-4)

Step 2: Low-intensity CBT e.g. computer-based, guided self-help, group CBT, motivational interviewing

Step 3: Individual CBT, counselling, IPT

Step 4: Intensive, specialist CBT/IPT/DBT/CAT


Four areas of focus of interpersonal therapy

One of:

  • Grief
  • Managing transitions
  • Interpersonal deficits (social impoverishment)
  • Interpersonal disputes


What is DBT?

Dialectical behaviour therapy

Used for BPD patients

Skills in coping with emotional distress and problem-solving, allow more adaptive responses


Techniques of DBT

  • Individual:
    • Validation of emotions
    • Identifying maladaptive behaviorus + their triggers
    • Reinforcing adaptive behaviours
  • Group:
    • Mindfulness techniques
    • Emotional modulation techniques
    • Interpersonal skills: e.g. communication, conflict resolution
    • Distress tolerance skills: Self-soothing, distraction
  • Other:
    • Telephone between sessions for 'real-life' application
    • Therapist support groups


Uses of motivational interviewing

Substance abuse

Risky behaviour in adolescents

Smoking/substance use in pregnancy

Behavioural change desired (e.g. in ED)


Role of supportive psychotherapy

Recent onset problems: Short-term support to weather transitions/adjustment

Mild depression (Esp if one episode, trigger known)

Mild-moderate anxiety


Techniques in systemic family therapy

60-90min every 2-4 weeks

One therapist + reflective team behind one-way screen, or two therapists reflecting in front of family

Highlight strengths, share ideas, find solutions

Concerned with:

  • Power distribution within system
  • Communication
  • Attachment
  • Intergenerational scripts/roles