Psychological treatments And Therapeutics

Question 1

When do NICE recommend ECT to treat depression?

Answer 1

Severe depressive episodes that are life threatening or require rapid response

Question 2

Short term side effects of ECT

Answer 2

Headache
Muscle pain
Nausea
Temporary memory loss
Confusions

Question 3

Long term side effects of ECT

Answer 3

Persistent memory loss

Question 4

Risks of ECT due to induced seizure

Answer 4

Damage to teeth and mouth
Risk of GA
Small risk of death

Question 5

Possible indications for ECT?

Answer 5

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

Question 6

Examples of medications used to manage ADHD

Answer 6

Central nervous stimulants:

Methylphenidate (“Ritalin“)
Dexamfetamine
Atomoxetine

Question 7

Children with ADHD managed by Methylphenidate required what monitoring and why?

Answer 7

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.

Question 8

What is ERP and how is it used to manage OCD?

Answer 8

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

Question 9

IAPT appropriate presentations

Answer 9

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

Question 10

IAPT exclusion criteria

Answer 10

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’

Question 11

Potential side effects of ECT

Answer 11

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

Question 12

When might ECT be used?

Answer 12

Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms.

Question 13

Contraindication against ETC

Answer 13

The only absolute contraindications is raised intracranial pressure.

Question 14

Aspects/principles of dialectical behavioural therapy (DBT)

Answer 14

mindfulness
acceptance
distress
tolerance
emotional regulation

Question 15

What is psychotherapy?

Answer 15

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.

Question 16

Common features of all psychological therapies?

Answer 16

• 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

Question 17

Which psychotherapies are available on the NHS?

Answer 17

Psychodynamic Psychotherapy

Behavioural and Cognitive Psychotherapies (cognitive-behavioural therapy or CBT)

Interpersonal Therapy (IPT)

Family/systemic therapies

Question 18

In which settings can psychotherapies be delivered?

Answer 18

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)

Question 19

Counselling vs psychotherapy

Answer 19

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

Answer 20

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

Question 21

What is psychodynamic psychotherapy and what does it involve?

Answer 21

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

Question 22

When might psychodynamic psychotherapy be suitable?

Answer 22

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.

Question 23

What are behavioural therapies and CBT and what does it involve?

Answer 23

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.

Question 24

When might behavioural therapies and CBT be useful

Answer 24

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.

Question 25

What is IPT and what does it involve?

Answer 25

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.

Question 26

Utilisation of IPT

Answer 26

The utilisation of IPT has expanded from depression to other disorders, including eating disorders.

Question 27

What are family/systemic therapies and what is involved?

Answer 27

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.

Question 28

When is family therapy utilised?

Answer 28

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.

Question 29

What are the principal differences between psychodynamic psychotherapy and cognitive- behavioural psychotherapy?

Answer 29

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

Question 30

What is “transference”?

Answer 30

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

Question 31

Why is motivation important in assessing a patient’s suitability for psychodynamic psychotherapy?

Answer 31

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

Question 32

Why do patients in some forms of therapy often get worse before they get better?

Answer 32

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

Question 33

What specific techniques may be used in CBT?

Answer 33

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

Question 34

Why might some patients be viewed as unsuitable for psychotherapy?

Answer 34

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).

Question 35

Which section/form would need to be completed to initiate emergency ECT?

Answer 35

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.

Question 36

ECT and memory loss

Answer 36

Short-term memory loss – this resolves completely in most cases, although memory tests should be performed throughout treatment to monitor for significant memory loss.

Question 37

Prior to ECT what should be obtained/done?

Answer 37

Informed consent, written information, support from advocate, family member, or friend Full physical examination ECG CXR if indicated Bloods Anaesthetic review

Question 38

How often and for how long is ECT used?

Answer 38

6-12 sessions, twice weekly Stopped as soon as patient has maximum benefit Inpatient or outpatient

Question 39

What is monitored during ECT

Answer 39

Blood pressure O2 (sats) ECG leads EEG (brainwaves, seziure activities)

Question 40

ECT: eating and drinking

Answer 40

NBM 6 hours prior to treatment

Question 41

What is given to patient during ECT

Answer 41

General anaesthetic Suxamethonium (muscle relaxant, prevent full blown seizure activity) Oxygen

Question 42

Most common memory impairment due to to ECT?

Answer 42

Anterograde impairments, may persist between and rarely after treatments

Question 43

How does ECT seizure activity differ from a normal seizure?

Answer 43

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

Question 44

In what situations is ECT sometimes used and seen to be effective although not advised by guidelines

Answer 44

Routine management of schizophrenia maintenance therapy

Question 45

What should be assessed following each ECT session

Answer 45

Mental state

Question 46

Why are mouthgaurds used in ECT

Answer 46

Cheek or tongue bite Damage to teeth

Question 47

Prolonged seziure in ECT

Answer 47

More than 2 mins - seziure aborted

Question 48

If memory loss is of particular concern in ECT, what can be done?

Answer 48

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

Question 49

How many ECT sessions are required for most patients with severe depression?

Answer 49

8-10

Question 50

How long does ECT generally take per patient

Answer 50

one hour (20 min pre covid)

Question 51

What is meant by MODIFIED ECT

Answer 51

Under GA, this is how it is performed in developed countries

Question 52

How is ECT regulated

Answer 52

ECTAS - ECT accreditation services

Question 53

ECT - cautions/contraindications

Answer 53

1. Raised intracranial pressure, cerebral aneurysm, recent cerebrovascular event 2. MI within 3 months, unstable angina, DVT, K+ imbalance, uncontrolled HR/BP 3. Acute respiratory infection, other respiratory conditions 4. Recent food/fluids/chewing gum/cigarettes/sweets 5. Cochlear implants, Phaeochromocytoma, unstable fractures, bariatric pts 6. Pregnancy, controlled epilepsy, pacemakers-not necessarily contraindicated

Question 54

Physiological changes during ECT

Answer 54

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

Question 55

Potential mechanisms of benefits from ECT

Answer 55

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

Question 56

Consent for ECT

Answer 56

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

Question 57

ECTAS monitoring standards

Answer 57

* 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

Question 58

In ECT, what medications does the anaesthetist administer and why?

Answer 58

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

Question 59

New neuromodulation techniques

Answer 59

Transcranial Magnetic stimulation (rTMS) Vagus nerve stimulation (VNS)

Question 60

What is Projection

Answer 60

Projecting the conflict outside the self

Question 61

What is sublimation

Answer 61

Attaining the gratification in an acceptable way

Question 62

What is Reaction Formation?

Answer 62

Doing the opposite of the initial desire

Question 63

What is splitting?

Answer 63

Separating the conflict as ‘all good’ or ‘all bad’

Question 64

What is Repression?

Answer 64

Consciously postponing the conflict for later

Question 65

What is Acting Out

Answer 65

Discharging the anxiety as an outburst

Question 66

What is introjection?

Answer 66

Acquiring qualities of others as parts of our self

Question 67

Ego Defence Mechanisms

Answer 67

Projection Splitting Suppression Sublimation Reaction Formation Acting out Introjection

Question 68

What is projective identification

Answer 68

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

Question 69

What is meant by internal objects

Answer 69

In essence, the term 'internal object' means a mental and emotional image of an external object that has been taken inside the self

Question 70

What is unconscious phantasy?

Answer 70

Unconscious explanation of things Influenced by internal objects dictates emotional responses

Question 71

What is countertransference?

Answer 71

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.

Question 72

Principles of attachment theory

Answer 72

•Safety and Security •Explore and Share •Emotional bonds •Part of personality •Internal Working Model

Question 73

CBT: cognitive triangle

Answer 73

THOUGHTS: BEHAVIOUR EMOTIONS

Question 74

Becks cognitive triad

Answer 74

Depression - cognitive triangle one way, pathological

Question 75

CBT: key practice ideas

Answer 75

Socratic questioning •Formulation •CBT models of disorder •Problems and targets/goals •Collaboration •Homework •Making the patient their own therapist

Question 76

What is a formulation

Answer 76

•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

Question 77

What is a formulation in CBT for?

Answer 77

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)

Question 78

What qualities should a formulation have?

Answer 78

•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

Question 79

How do we create a formulation

Answer 79

•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!

Question 80

Socratic questioning

Answer 80

•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...?'

Question 81

role of socratic questioning in CBT

Answer 81

•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

Question 82

CBT: problems and goals

Answer 82

•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

Question 83

CBT: Collaboration, homework, patient as therapist

Answer 83

•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

Question 84

Key theory: levels of cognition

Answer 84

Question 85

Cognitive distortions

Answer 85

•All or nothing •Over-generalisation •Selective negative focus •Disqualifying the positive •Arbitrary inference •Magnification or minimisation •Emotional reasoning •Should statements •Labelling and mislabelling •Personalisation

Question 86

Cognitive interventions

Answer 86

•Thought diaries and challenging •Positive data logs •Continuum work •Responsibility charts •Imagery •Surveys •Theory A vs Theory B •Thought challenging

Question 87

Behavioural interventions

Answer 87

•Exposure •Diary work •Nutrition & Energy •Sleep management •Behavioural Activation •Re-establishing Structure •Ruminating •Behavioural experiments

Question 88

CBT: exposure

Answer 88

•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

Question 89

What is an evidence based treatment for BPD/EUPD

Answer 89

dialectical behavioural therapy - a synthesis or intervention of opposites thesis + antithesis -> synthesis

Question 90

What is DBT

Answer 90

Mix of CBT, behaviourism, and mindful practices Recognising importance of rational and emotional realms of mind Seeks a mid path between - ‘ Wise mind’

Question 91

What is distress tolerance

Answer 91

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

Question 92

When to use distress tolerance skills

Answer 92

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

Question 93

DBT: goal of emotional regulation

Answer 93

Naming and understanding our own emotions Decreases the frequency of unpleasant emotions Decrease our vulnerability to emotions Decrease emotional suffering

Question 94

Interpersonal effectiveness

Answer 94

Learning to get along with others whilst also asserting your own needs is essentiel to healthy relationships

Question 95

CBT indications

Answer 95

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

Question 96

How is CBT delivered

Answer 96

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.

Question 97

Circumstances in which cognitive– behavioural therapy is indicated

Answer 97

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

Question 98

Target problems for CBT

Answer 98

Extreme of unhelpful thinking Reduced activity Avoidant or unhelpful behaviours

Question 99

What does CBT involve?

Answer 99

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.

Question 100

Unhelpful thinking styles: People with depressed and anxious thinking tend to show certain common characteristics

Answer 100

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

Question 101

CBT- five areas model

Answer 101

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

Question 102

Issues relating to life situations/relationships, and practical problems

Answer 102

• Debts, housing or other difficulties • Problems in relationships with family, friends, colleagues, etc. • Life events such as deaths, redundancy, divorce, court appearance.

Question 103

Examples of mood states that may be described by patients

Answer 103

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.

Question 104

Depression vs anxiety - altered emotions

Answer 104

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

Question 105

Identifying reduced activity in depression

Answer 105

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.)?

Question 106

Idefntigying areas of avoidance in anxiety

Answer 106

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?

Question 107

Identifying unhelpful behaviours

Answer 107

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?

Question 108

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?

Answer 108

Psychodynamic psychotherapy

Question 109

Psychodynamic therapy vs psychoanalysis

Answer 109

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.

Question 110

What is psychoanalysis

Answer 110

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.

Question 111

Patient factors to consider when selecting a psychotherapy

Answer 111

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

Question 112

Aspects of problem formulation

Answer 112

Behavioural Cognitive Dynamic Sy temic

Question 113

Principles of treatment planning

Answer 113

Least necessary intervention Collaborative process Based on formulation Meet (& treat?) family Provisional treatment contract

Question 114

DBT

Answer 114

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.

Question 115

Antidepressant therapy in ECT

Answer 115

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

Question 116

What type of amnesia might ECT cause

Answer 116

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)

Question 117

What is displacement

Answer 117

Displacing feelings - angry at person A due to something person B has done