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Flashcards in Physical/psychological treatments Deck (24):
1

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

 

2

Indications for ECT

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

Moderate depression: Prolonged, resistant to multiple drugs + psychotherapy

Mania + psychosis: Prolonged/severe

Catatonia/NMS

3

Physiological effects of ECT

Raised pressures: Intraocular, intragastric, hypertension

Dental: Supraphysiological bite

Cardiac: Emergent arrhythmias

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

4

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

5

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

6

Length of ECT treatment

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

7

Consent and capacity frameworks for ECT

Voluntary:

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

Detained:

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

8

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

 

9

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)

10

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

11

Efficacy of rTMS

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

12

Side effects of rTMS

Headache, facial discomfort

Syncope occasionally

Rarely seizure induction

13

Contraindications for rTMS

Epilepsy, stroke, brain tumour

14

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

15

Common negative cognitive biases

All-or-nothing thinking

Catastrophising

Overgeneralising

Disqualifying positives/focusing on negatives

Labeling/jumping to conclusions

Personalisation

16

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

17

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

18

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

19

Four areas of focus of interpersonal therapy

One of:

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

20

What is DBT?

Dialectical behaviour therapy

Used for BPD patients

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

21

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

22

Uses of motivational interviewing

Substance abuse

Risky behaviour in adolescents

Smoking/substance use in pregnancy

Behavioural change desired (e.g. in ED)

23

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

24

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