• Psychotherapy

    by  • 22/12/2013 • Psychiatry

    Describe the basic principles and applications of:

    • Counselling and supportive therapy

    • Behavioural therapy (response prevention, systematic desensitisation, relaxation therapy)

    • Cognitive therapy (including CBT and anxiety management) = CBT can be used to tx: personality conditions, behavioural problems, alcohol and drug abuse pts, stuttering, anxiety disorders, mood disorders, uni and bi-polar, schizophrenia, post-traumatic stress disorder, insomnia…

    • Family therapy = is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members. It emphasizes family relationships as an important factor in psychological health.

    You should be aware of the existence of psychodynamic theory and therapies and their clinical applications.

    Principles of Pharmacotherapy and related management

    • Describe the clinical indications of the following drugs

    • Hypnotics: are a class of psychoactives whose primary function is to induce sleepand to be used in the treatment of insomnia and in surgical anesthesia. Ex = benzodiazepines, non-benzo’s, opioids, barbiturates, anti-histamines, melatonin agonsists…

    • Anxiolytics: a class of drug used for the treatment of anxiety, and its related psychological and physical symptoms. Ex: benzo, barbiturates, pregabalin, hydroxyzine, azapirones, SSRIs…

    • Mood stabilising agents: are a class of drugs used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder. Ex: sodium valproate, lamotrigine, carbamazepine, gabapentin, lithium, some atypical antipsychotics. Most mood stabalzing agents are anti-manic drugs, rarely do they help in tx of depression, therefore mood sstabalizers are often prescribed alongside an anti-depressant drug

    Describe alcohol withdrawal management: discussed

    Describe the symptoms and management of movement disorders

    • Extra-pyramidal side effects: parkinsonian s/e’s as described and linked to typical anti-psychotics

     

    • Acute dystonia:  is a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal posture.

    • Akathisia: is a syndrome characterized by unpleasant sensations of “inner” restlessness that manifests itself with an inability to sit still or remain motionless. Can be a s/e of: antipsychotics, SSRIs, venlafaxine, opioids, cocaine, amphetamines, benzo’s, alcohol…

    • Tardive dyskinesia: is a difficult-to-treat form of dyskinesia (disorder resulting in involuntary, repetitive body movements) that can be tardive (having a slow or belated onset). It frequently appears after long-term or high-dose use of antipsychotic drugs. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements, such as grimacing, tongue protrusion, lip smacking, puckering and pursing of the lips, and rapid eye blinking.

    Describe the symptoms and management of…

    Signs and symptoms =

    Cognitive effects: headache, agitation, hypomania, mental confusion, hallucinations, coma

    Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhea.

    Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.

    Electroconvulsive therapy

    Indication:failure of previous anti-depressant medications, previous success with ECT, if a definitive response is critical (risk of harm to self or others, or experiencing psychotic symptoms).

    Use in: mania, catatonia, schizoaffective disorders, refractive depressive disorders, epilepsy… it is thought to be safe for use in pregnant, children, diabetic and obese – but with caution.

    Mechanism of action:The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive

    Risk of relapse: high ~6/12, but can be reduced by regular cycles of ECT and the addition of psychomedications…

    Risks of ECT: few, just that of GA. Death rate is 4/100,000 applications. The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). There is quite a lot of controversy over the long term risks and benefits of ECT.

    Epidemiology: ~70% of ECT pts are women.

    Administration:

    • Informed consent is sought before treatment: risks, benefits, other options…
    • Prior to treatment a patient is given a short-acting anaesthetic such as methohexitaletomidate, or thiopental, a muscle relaxant such as suxamethonium, and occasionally atropine to inhibit salivation.
    • Both electrodes can be placed one on the same side of the patient’s head = unilateral ECT. Unilateral ECT is used first to minimize side effects (memory loss).
    • Placed on both sides of the head = bilateral ECT.
    • The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual’s seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT
    • Seizure threshold is determined by trial and error (“dose titration”). Some psychiatrists use dose titration, some still use “fixed dose” (that is, all patients are given the same dose) and others compromise by roughly estimating a patient’s threshold according to age and sex.

     

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