ICC-2 Psych — Psychological Treatment

Core features

• Onset childhood/adolescence into adult life; enduring + pervasive
• Affective instability (rapid intense responses, slow return to baseline); impulsivity; self-destructive/para-suicidal behaviour
• Intense unstable relationships; frantic efforts to avoid abandonment
• Cognitive: paranoia, quasi-psychotic experiences, depersonalisation
• Impulsivity forms: self-harm, alcohol/drugs/food/overdose, eating disorders, promiscuity, spending
• Self-harm: cutting, burning, mutilation, piercing, scarification; para-suicidal: overdose, blood-letting, self-stabbing

Presents / epidemiology

• A&E post-self-harm · admission after interpersonal crisis · GP requesting sedatives/antidepressants · surgery for self-mutilation repair
• Prevalence: general 1% · psychiatric outpatients 10% · inpatients 20% · forensic 70%

Aetiology

• Biological factors + early attachment relationship + subsequent experiences/trauma
• Secure attachment → attuned caregiver metabolises distress → stable sense of self + affect regulation
• Failed attachment → disorganised pattern → unstable self; non-metabolised distress displaced onto body (self-harm) or projected into relationships

Management

• Mainstay psychological; structured programme in specialist PD service; brief interventions CONTRA-INDICATED; watch transitions, splitting, acting-out
• DBT (1990s, Linehan; from behaviour therapy) — targets problematic behaviours only (cutting/overdose), NOT emotions/interpersonal; best for impulsive self-harming women
• MBT (2004, Bateman & Fonagy UCL; from attachment theory) — targets thoughts/feelings of self + others
• Both DBT + MBT: individual + group, 18–24 months, NICE-recommended
• Prognosis: 10% suicide, rest gradually improve

Special

• Projective identification — emotional conflict projected → becomes interpersonal conflict others find themselves in
• Counter-transference hatred — clinicians drawn into rows / derogatory or sadistic care / no anaesthetic before suturing self-harm / inappropriate sedative prescribing

Approaches & context

• 8 common MH problems: anxiety · depression · PTSD · OCD · psychosis/schizophrenia · bipolar · somatoform · personality disorders
• Providers: psychologist · psychotherapist · psychiatrist · psychological practitioners · IAPT high/low-intensity workers
• Contexts: IAPT + secondary care · Formats: individual/group/family/consultation · needs motivation to engage
• 3-stage structure: assessment → formulation → treatment/intervention
• 3 main approaches practised in NHS: systemic · CBT · psychodynamic

• Butler (1998): the tool relating theory to practice — 'hypotheses to be tested'
• All formulations (Johnstone & Dallos 2006): summarise core problems · relate difficulties to one another · use theory to explain development/maintenance (triggers, situations, maintaining factors) · indicate intervention plan · open to revision

Theory

• Beck's cognitive theory; early childhood → schemas/core beliefs about self, others, world
• Schema = cognitive framework organising/interpreting info; critical event → unhelpful thinking + negative automatic thoughts → affect feeling + behaviour
• Longitudinal (Beck): schemas = categorical ('I am unlovable') → assumptions = conditional → critical incident → activated schemas → NATs → emotions/behaviours/bodily sensations
• Vicious cycle: attempts to solve a problem inadvertently maintain it

Method

• Individual/group · time-limited 8–20 sessions · collaborative · active (out-of-session work) · assess → formulate → intervene

Techniques

• Sharing the formulation (treatment rationale) · Socratic questioning · thought diaries · thought challenging (evidence) · behavioural experiments · homework ('client becomes their own psychologist')

Evidence

• Most developed evidence base of all therapies (Cochrane 2009)
• NICE-recommended: depression (2009), schizophrenia (2009), anxiety (2011), eating disorders (2004), bipolar (2006)

Key concepts

• 5 concepts: unconscious · free association · defences · transference · development

Freud's models

• Topographical: unconscious (repressed wishes, pleasure principle, slips/dreams) · preconscious · conscious
• Structural: Id (from birth, unconscious, pleasure/instincts) · Ego (age 1, largely conscious, defences) · Superego (age 5–6, unconscious, morals/values)

Contributors

• Bowlby (attachment theory) · Bion (container-contained) · Jung (analytical psychology — introvert/extrovert, archetypes, complex) · Winnicott (good-enough mother, transitional object)

In practice

• Setting · exploration · interpretation · transference; links made: conscious↔unconscious (defences), therapist↔patient (transference), inner↔outer reality → symptom relief + wellbeing
• Interpretation (verbal): identify defence · identify feeling · address feared consequences · use of transference · counter-transference
• Formats: individual/couples/groups/systems; derived modalities: MBT, interpersonal therapy, organisational consultancy

Clinical features

• Compulsive need to control eating + body shape (both sexes); weight loss becomes an over-valued idea (feels "fat" even when very underweight)
• Females want to be "thin"; males want high muscle mass rather than thinness; shape "achieved" by food refusal → over-exercise, induced vomiting, laxative abuse
• Perfectionism, poor concentration/exhaustion, intolerance of cold, inflexible thinking
• Secretive/changed eating + exercise (calorie counting, refuses food when upset), obsession with weight, makes food for others, tension with others (believes nothing is wrong)

Starvation — whole-body effects

• Brain: poor thinking/memory, fear of weight gain, low/irritable mood, fainting
• CVS: low BP, bradycardia, palpitations, heart failure
• Bloods: anaemia; low potassium, magnesium, sodium
• MSK: weak muscles, swollen joints, fractures, osteoporosis
• Renal: kidney stones, kidney failure · GI: constipation, bloating
• Endocrine: periods stop, bone loss, reduced fertility (pregnancy → ↑ miscarriage, C-section, low birthweight, postpartum depression)
• Skin: easy bruising, dry skin, fine hair growth all over body, cold intolerance, yellow skin, brittle hair/nails

Investigations / assessment

• Physical risk stratification — BMI, weight-loss rate, BP, pulse, postural BP drop, squat test, temperature (→ Medium- vs High-risk; see Criteria tab)
• Bloods: potassium (hypokalaemia → arrhythmia / seizures) + electrolytes
• ECG: prolonged QT (arrhythmia risk)

Management

• Mild: support, self-help books, food diary; refer to specialist if no improvement; explore comorbidities (depression, ASD); physical health = priority; do not allow disengagement (often in denial)
• Restore nutrition: weight gain 0.5–1 kg/week (~3,500–7,000 extra kcal/week); aim final BMI 20–25; treat starvation + refeeding complications
• Family-based treatment (FBT) > individual — conjoint (CFT) or separated (SFT) family therapy; Maudsley model → full recovery up to 90%
• Individual therapy usually ACT (acceptance & commitment therapy, a type of CBT); involve family/carers (avoid blame)
• Hospital admission per weight/severity; CAMHS referral in adolescents

Special

• Types — Restricting (dieting/fasting/exercise, no binge-purge in last 3 mo) vs Binge-eating/purging (recurrent binge/purge in last 3 mo)
• Cognition worsens as BMI falls (see BMI–brain table); serotonin dysregulation + 55% concordance in monozygotic twins
• Prognosis: ⅓ recover fully, ⅓ improve, ⅓ chronic; 5% die (suicide or medical — hypokalaemia + prolonged QT → arrhythmias); median diagnosis→death ~11 years

Clinical features

• Recurrent binge eating + inappropriate compensatory behaviours (self-induced vomiting, laxatives, diuretics, enemas, excessive exercise)
• Self-evaluation unduly influenced by body shape; often normal weight
• Social isolation, avoiding relationships (pressure to eat / exhaustion), excessive time in bathroom after eating

Complications (severe)

• Vomiting → kidney damage; oesophageal damage (incl. sore throat); bowel damage
• Dental: tooth erosion, decay, bad breath; swollen salivary glands; hormonal changes
• Potassium disturbance → heart-rhythm changes / seizures; weakness, tiredness

Management

• Treat medical complications (e.g. of vomiting)
• Antidepressant for binges/purging — first-line SSRI (fluoxetine) at a higher dose than for depression: 60 mg
• Consider CBT rather than family therapy

Special

• Prognosis: over 2–10 years, 50% recover, 20% no change; mortality higher with delayed treatment or predominantly vomiting

Clinical features

• Recurrent binge eating (≥1×/week for 3 months): large amount of food in a discrete period (e.g. ≤2 h) + loss of control
• Eating rapidly, when not hungry, until uncomfortably full; eating alone from embarrassment; guilt afterward; marked distress

Special

• Unlike other EDs, no compensatory behaviour → does not prevent weight gain, so obesity is common
• Comorbid with depression, low self-esteem, boredom

Clinical features

• Potentially fatal; follows rapid reintroduction of food after ≥10 days of undernutrition
• Signs: rhabdomyolysis, respiratory failure, low BP, arrhythmias, seizures, sudden death

Investigations

• Monitor serum phosphate (stop refeeding if falling); also watch rising glucose or falling potassium

Management

• Dietician-led slow refeeding, cautious calorie increase over 4–7 days
• Milk often used initially (phosphate-rich, well tolerated)
• Prescribe thiamine, strong vitamin B complex, and a multivitamin

Special

• Caused by decreased blood phosphate (hypophosphataemia)

BATHE technique

• Background · Affect · Trouble · Handling · Empathy

Brief psychiatric history — structure

• Complaint: patient's own words (spontaneous + on questioning); informant if available & consented
• HPC: onset / course / duration, nature of problem, frequency / timing, precipitating / aggravating / relieving factors, treatment taken & response — then screen for other psychiatric symptoms
• Past psychiatric history: previous diagnoses / episodes, admissions, treatments that did & didn't work (medications, psychotherapy, ECT), any deliberate self-harm (DSH) / suicide attempts
• Past medical history: esp. vascular risk factors (diabetes, hypertension, cholesterol), fever admission, significant head trauma, surgery
• Medications: type / dose / frequency, route (oral or depot injection), allergies; OTC — vitamins, analgesics, supplements, herbal
• Family history: medical / psychiatric — esp. epilepsy, intellectual disability, criminality, substance misuse, morbid religiosity, suicide
• Substance history (see below)

Substance history

• Substances: smoking (cigarettes / cigars / pipe / shisha), alcohol (units/week), illicit — cannabis, opiates (heroin, tramadol), stimulants (cocaine, amphetamines), hallucinogens (LSD, ecstasy, MDMA)
• For misuse: when started, most at heaviest, periods of abstinence, current amount & cost, ever injected (HBV / HIV risk + tests), blackouts / withdrawal, does the patient see it as a problem?

Adapting to the patient

• Talkative → "out of all these problems, what is the most troublesome for you?"
• Silent → structured questions to open them up; reassure they have coped so far, then explore their coping strategies

Descriptive psychopathology

• Phenomenology — observation & categorisation of abnormal psychic events without embellishing with cause or function; empathic evaluation of the patient's subjective experience

NICE depression screen (2 questions — mood + interest)

• "During the last month, have you often been bothered by feeling down, depressed or hopeless?"
• "During the last month, have you often been bothered by having little interest or pleasure in doing things?"

Asking about mood

• "Have you been feeling sad or tearful?" · "Could you tell me more about that?" · anything you've been able to enjoy over the last couple of weeks? · ways of keeping your spirits up in hospital?

Asking about anxiety

• "Have you been feeling anxious?" · tell me more about those worries · how long · how has it affected you · what coping techniques do you have when stressed?

Asking about sleep

• Enough sleep? how many hours? continuous or interrupted? struggle to get to sleep? ever wake very early and can't get back?

Asking about self-harm & suicide

• Emotive — find your own wording, e.g. "Sometimes when people feel particularly stressed, worried or low, they can have thoughts of harming themselves or ending their lives — has this ever happened to you?" then "If it did, who could you talk to about it?"

Technique

• Socratic questioning (shared critical thinking): clarify their thinking, challenge assumptions, request evidence, explore implications, question the question
• Normalising: to elicit ("some patients tell me this can be frightening") or reassure ("that's a very common experience"); a symptom is more likely a disorder if intense + persistent
• Balance open & closed questions; psychiatric symptoms are subjective (pain, fatigue, worry, panic) → need description + empathy, not a rigid SOCRATES
• Don't read a fixed verbatim list; judge mood (cheerful / downcast / withdrawn) and adapt; be curious not invasive; avoid jargon; be human

Depression — symptoms

• Core: low mood (diurnal variation), loss of interest / enjoyment, fatigability
• Psychological: poor concentration, low self-esteem, guilt, pessimism
• Somatic: sleep disturbance (esp. early-morning waking), anorexia + weight loss, loss of libido

Anxiety — symptoms

• Psychological: fear / "impending doom", restlessness, dizziness / faintness, exaggerated startle, poor concentration, irritability, insomnia / night terrors, depersonalisation / derealisation, globus hystericus
• Physical (autonomic arousal, hyperventilation, muscle tension): CVS — tachycardia, palpitations, chest pain; GI — dry mouth, globus, nausea, abdominal pain, loose stools; Resp — SOB, chest tightness; GU — frequency, erectile dysfunction, amenorrhoea; Neuro — tremor, headache, muscle pains, paraesthesia

Classification

• Anxiety disorders: PTSD · panic disorder · OCD · GAD · phobias
• Mood disorders: depression (dysthymic, major) · bipolar (I, II, cyclothymic)
• Major psychiatric diagnoses: schizophrenia, bipolar, depression, dementias, learning difficulties, personality disorders, substance misuse

Definition

• The link / connection — psychiatrists providing psychiatric care to medical patients; psychiatry = diagnosis + management of disorders of mental function (cf. psychologists, psychoanalysts, psychotherapists)

Scale of the problem

• >1/4 of hospital patients have a mental disorder; 2/3 of beds are older people, of whom ~60% have or develop a mental-health condition — most often dementia, delirium, depression
• Comorbid mental + physical illness: often undiagnosed, ↑ morbidity / mortality, ↓ quality of life, poorer pain control, ↓ treatment compliance, ↑ healthcare use, may mask physical problems, stigma
• Under-recognition: >half of depression in general hospitals is missed — symptom overlap, normalisation, stigma, time constraints, physician reluctance to ask

4 ways psychiatric symptoms occur with medical disease

• Direct result of physical disease · psychological reaction to disease · psychiatric disorder → physical symptoms · psychiatric disorder presenting as a physical disorder

Scope of liaison psychiatry

• Psychological reaction to illness, delirium, dementia, disturbed behaviour, self-harm, substance use, medically unexplained symptoms, capacity, severe mental illness / psychosis, perinatal psychiatry
• Illnesses treated: functional / non-organic, organic, learning disability, personality disorders; classifications used — ICD-10 & DSM-5

Reaction to illness

• ~1/4 of people with a physical health problem develop psychological problems
• Driven by: loss of identity / role, loss of function, lifestyle change / disability, dependency on others, impaired relationships, deterioration / threat to life, impact on body image + self-esteem
• Factors influencing response: illness perception, coping strategies, personality; illness type (↑ psychiatric morbidity with more pain, advanced disease, high disability, brain-affecting neuro disorders); therapeutic setting

Adjustment disorder

• Onset within 1 month of an identifiable (non-catastrophic) psychosocial stressor
• Depressed or anxiety reaction (or conduct disorder in children)
• Usually resolves <6 months after the stressor ends (unless a prolonged depressive reaction)

Adjustment disorder vs onset of mental illness — red flags for mental illness

• Persistent / extreme / disabling mood change, bizarre symptoms (psychosis, aggression), maladjustment to illness, suicidality, physical function poorer than expected, slower recovery than expected, poor social interaction

Kübler-Ross grief / change curve

• Shock → numbness → denial → fear → anger → depression → understanding → acceptance → moving on

General rule

• Diabetes / hypertension / CAD → ×2 depression (+ vascular dementia risk); COPD / cerebrovascular / other chronic → ×3; ≥2 chronic conditions → ×7 more likely to have mental-health problems

By condition

• Cardiac (CAD): ~20% clinically significant depression post-MI or at cardiac catheterisation; depression in CVD 17–27%; comorbid depression → more cardiac complications
• Diabetes: depression ~9% (×2) → poorer glycaemic control, complications, ↑ death; needle phobia; insulin misused for weight loss; insulin overdose risk
• COPD: ×2.5 depression / anxiety (worse if hypoxic / dyspnoeic), up to 50%; panic common — "suffocation false alarm" (brainstem chemoreceptors, lactate) + hyperventilation → hypocapnia → anxiety; catastrophic cognitions; steroids → psychosis / depression
• Cancer: depression / anxiety / adjustment / delirium common; can present psychiatrically — brain tumours (1° / metastatic), small-cell lung, pancreatic (insulinoma → neuropsychiatric, misdiagnosed as psychosis / depression); head & neck cancer → high suicide
• SLE: depression / anxiety (rarely psychosis); CNS — seizures, chorea, cognitive impairment, stroke
• Multiple sclerosis: depression 40–50% (×3), ↑ suicide; SSRIs first-line; ECT ~20% relapse risk; steroid-induced mania / depression (also baclofen, dantrolene, tizanidine)
• Stroke: post-stroke depression (mean ~34 weeks), more with basal-ganglia / left-hemisphere infarcts; screen within the first month; treat emotionalism with antidepressants, continue ≥4 months
• Epilepsy: depression 30–50%, panic ~20%, esp. TLE; high suicide (×25 with depression); SSRIs first-line; avoid lithium (lowers seizure threshold); post-ictal psychosis; pseudoseizures

Physical health of the mentally ill

• Schizophrenia / bipolar die 16–25 years earlier; ↑ respiratory, cardiovascular, infectious disease, obesity / dyslipidaemia / diabetes
• Schizophrenia: diabetes 10% → 20–25% at 60+; smoking 70% of inpatients (vs 21% general population)
• Depression itself: ×2 lifetime type-2 diabetes risk; independent risk factor for heart disease + stroke (psychotropic drug side-effects → see Psychopharmacology card)