Clinical Mental Health Live Session Notes PDF

**Clinical Mental Health Live Session Notes** **[Psychosis & Bipolar]** Psychosis - [Risks in psychosis]: self-harm, self-neglect and lack of caution, and harm to others. - 50-60% of individuals with acute psychosis are admitted within the first episode, often under Mental Health Act...

**Clinical Mental Health Live Session Notes** **[Psychosis & Bipolar]** Psychosis - [Risks in psychosis]: self-harm, self-neglect and lack of caution, and harm to others. - 50-60% of individuals with acute psychosis are admitted within the first episode, often under Mental Health Act. - Home management of acute psychosis is feasible depending on risks. - [Immediate needs when someone has acute & severe mental health problems]: - Assessment and management of risks - Further assessment of diagnosis - Assessment of hx, physical health, personality, coping, and support system - Decide further treatment - [Services available]: Acute inpatient wards, crisis houses & day hospitals, early intervention services, rehabilitations services, primary care, and community mental health teams. - [General principles of good psychosis care]: - Assessment and re-assessment - Multidisciplinary approach - Collaboration - Holistic approach (physical health, social care) - Recovery - Kindness and compassion - [Early intervention for psychosis]: - Mandatory since 2001 in UK. - Specialist services are involved from the beginning even while inpatient and crisis interventions. - Aims: improve recovery, detect psychosis in community - [Antipsychotic medication]: - Around since 1950's - Used typically to treat positive symptoms - 81% will improve with antipsychotic, 52% w/o in acute psychosis. - Most improve within 6 weeks to 6 months. - Effects: reduce positive symptoms and mania, but little to no effect on negative symptoms. - Side effects: weight gain, metabolic syndromes, motor side effects, sedation, cardiac arrhythmias. - Dopamine over-activity in mesolimbic system may be a cause of positive symptoms. (dopamine hypothesis) - [Psychological interventions]: psychoeducation for individual, peers, and family; rehabilitation, CBT, third wave CBT (acceptance and commitment), Art and music therapies, and cognitive remediation (cognitive training to improve cognitive deficits in schizophrenia, such as planning and organization), family therapy. - Open dialogue: innovative approach to developing dialogues at the time of psychotic crisis. - Physical health in psychosis: - 15-20 years earlier death (cardiac and suicide) - Comorbid: depression, drugs and alcohol abuse, anxiety Bipolar - Risks in mania: - Severe recklessness - Physical illnesses and injury - Overspending - [Interventions]: medication (mood stabilisers), psychoeducation, social support, CBT - Medications: antipsychotics first in UK (acute states), mood stabilisers (valproate, carbamazepine, and lamotrigine) added if antipsychotic is not working, lithium, antidepressants. - [General management]: self-care, calming activities, sleep routines, stress management, coping strategies, identifying signs of relapse, collaborative plans with family/ support systems, risk management. - Bipolar depression is not easily distinguished from depression in people without bipolar disorder and has less attention in mania. **[Culture & Diversity]** - Culture is not static and can change based on social class, geographical location, or generational status. - Ethics is more of a community right way of thinking and morals are individual. - [Universal principles]: - Respect for autonomy: assume pt has capacity to make their own decisions - Beneficence: beneficial to the population/ pt - Non-Maleficence: do no harm - Justice: equal care for all - System 1 bias: unconscious - System 2 bias: conscious **[Therapy w/ LGBTQ Population]** **[Dementia]** - Diagnosis is typically delayed due to people not believing they have any memory issue. - 1/3 of people with dementia have not received a diagnosis. - The hippocampus typically has atrophy in Alzheimer's disease - DLB creates lower levels of dopamine. **[Mental Health Care]** - [Primary mental health care]: GPs, Practice nurses, counsellors, primary care graduates. Mental health workers, health visits and midwives, psychological well-being practitioners. **[Assessments, Diagnosis, and Formulation]** - [Things you would want to ask during an assessment]: family hx, why are you here and what do you want to get out of this, risks, list of alcohol and medications, when did this start, what types of support have you had/ or have, physical illnesses, information about themselves (work, family, etc.), what was happening when the problem started, sleep and diet, and how they have been functioning. - [The 5 P's]: Problems, Predisposing factors, Precipitants, Perpetuating factors, Protective factors. (On MCQ) - [Formulation]: It is unique to the person you are assessing, and different for everyone. (not a diagnosis) **[CBT: ]** - ABC Model: activating events lead to beliefs and ended in consequences. - What you believe activates what you do, not necessarily what happened. - Thoughts and behaviour are the main mechanisms of change. - [Distinctive features]: - Collaborative: therapist and client work on an equal basis. Like a journey together. - Structured and active: working outside of the session as well. - Time limited: varies depending on the situation. Not necessarily short-term. - Empirical in approach: encourages research/ evidence based. - Problem orientated and goal focused - Guided discovery - [Levels of Cognition]: - Core beliefs: deep beliefs about ourselves, family, peers, life, etc. - (Dysfunctional) assumptions, rules, conditional beliefs: what your life experiences and how life has led you to believe. Learned. - (Negative) automatic thoughts: surface level thoughts **[Anxiety & Depression]** **Depression** **DSM-5 Criteria for Depression** A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. - Depressed mood - Decreased interest / pleasure in almost all activities - Significant changes in appetite / weight - Insomnia / hypersomnia - Psychomotor agitation/ retardation - Fatigue / loss of energy - Feelings of worthlessness / excessive or inappropriate guilt - Decreased ability to think / concentrate, or indecisiveness - Recurrent thoughts of death; suicidal ideation / attempt / planning B. Clinically significant distress OR impairment of function C. Not attributed to substances, medical condition or other Dx (e.g. Scz). No manic or hypomanic episodes. **Common Symptoms** - There is typically an overlap of symptoms. - Some of the symptoms are normal, but when it effects your daily life is when it becomes depression. - A score of 12 on CIS-R is when treatment is considered. **Depression in Context:** - Poverty, Racism, Stigma, Loneliness, Transphobia, Difficulty accessing healthcare, Difficult relationships, Homophobia, Societal misconceptions about mental health, Ableism, Judgement from others, Sexism, Bullying, Crime, Abuse, Classism, Long waiting times for support, Biphobia, Social isolation, Pressure to achieve. **How do we identify and treat depression?** - [Screening and Assessment]: - In UK, mostly in primary care settings though IAPT (NHS Talking Therapies) also accepts self-referral. - Internationally, general physicians often treat depression. - Screening -- NICE recommends two questions: - "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?" - Assessment: validated depression measures often used (e.g. PHQ-9) in primary care. - About half of the people who attend UK primary care with a mental health problem are not "detected" by the physician. - [Psychiatric Assessment of a Person with Depression]: (typically used in all assessments) - **History of presenting episode:** onset, duration, possible contributors, symptoms, impact on functioning. - **Personal hx:** parents and parenting, school, employment, relationships, important life events and circumstances, personality. - **Psychiatric hx:** hx of mental health problems, previous episodes of depression and previous treatment. - **Alcohol, substance use:** forensic hx. - **Mental State Examination:** behaviour, beliefs, experiences, symptoms, mood. - **Risk assessment:** suicide, self-harm, self-neglect, risk to others (not as common). - **Comorbidities:** screen for other differential diagnosis. - Their expectations from treatment and preferences. **Psychotic Depression** - Some people when depressed develop delusions and hallucinations as well as the symptoms listed in DSM or ICD. - The delusions and hallucinations are "mood congruent" i.e. they are depressive themselves. - For example, abusive hallucinations, delusions of worthlessness, that they are terminally ill, or their body and brain have rotted away. - This can be a medical emergency as can be associated with not eating or drinking, or with suicidal thoughts, especially in the elderly. **Assessment of Depression** - [Risk]: - Suicide: occurs 20.4 times more frequently in clients with major depression than in the general population. - Self-harm: associated with low mood. Under-reported. - Severe self-neglect: including not eating and drinking, not getting out of bed, and not speaking. - Occasionally harm to others -- e.g. delusions family might be harmed, or their future is hopeless. - [Safety planning] - [Areas to consider]: **Psychological Formulation of Depression (5 P's)** - [Predisposing Factors]: background, what made them vulnerable in the first place? - [Perpetuating Factors]: what is contributing to the depressive episode? - [Presenting Problem]: the current problem - [Precipitating Factors]: triggers? - [Protective Factors]: [ ] what can help? **How Do We Treat Depression?** - [Stepped Care Model]: model of healthcare delivery - Core features: - Treatment should be the least restrictive of those currently available (treatment intensity), but still likely to provide significant health gain. - The model is self-correcting, wherein non-response results in "stepping up" treatments. - Recommended by NICE for management of depression.  **Psychological and Pharmacological Treatments** - Typically offered as separate treatment options: - Antidepressants and psychological therapies (talking therapies). - Can be used in combination and evidence shows that this is more effective. - [Pharmacological treatment]: - First line treatment are **serotonin selective reuptake inhibitors** (SSRI): - Inhibit the reuptake of serotonin (or 5HT) into the presynaptic neuron. - Increase the level of serotonin transmission. - Have to be taken for several weeks for full benefit and people don't feel instantly better. - **SNRIs:** (e.g. venlafaxine) - Cause the blockade of the presynaptic reuptake of both 5HT and NA. - **NaSSAs:** (e.g. mirtazapine) - Blockade of the a2-adrenergic auto-receptor. - Side effects: sedation, weight gain. - **Less common:** - Monoamine oxidase inhibitors (MAOI) & tricyclics antidepressants (TCA). - **Antidepressant treatment:** - Discuss choice of drug, side effects, interactions, alternatives - SSRIs are typically first line, but if not effective: - Increase dose. - Switch to alternative antidepressant e.g. venlafaxine, mirtazapine. - Augment i.e. add in another drug -- antipsychotic, another antidepressant. - Always consider diagnosis and role of alcohol, substance use. - Evaluate social and psychological aspects and manage those as well. - Wait 2 to 3 months before changing medication. - [Effectiveness]: nearly 60% "feel better" after 12 weeks compared to only 42% who receive placebo. 25% have a "large response" compared to 10% on placebo. However, non-response to antidepressants is common. - [Side effects]: - For SSRIs" nausea, sexual side effects, emotional numbing. - Usually well tolerated but some people can not take the medication. - Venlafaxine and mirtazapine are less well tolerated than the SSRIs so used as second line medication. - [Discontinuation or withdrawal symptoms]: occur in about 30% of people when stopping antidepressants but 15% after a placebo. - Some estimates suggest up to 50% but research didn't consider "placebo discontinuation symptoms" - Severe symptoms occur in \~2% of people - Now recommended to taper medications, ie gradually reduce dose over a few weeks. - Venlafaxine has more discontinuation symptoms - **Electroconvulsive Therapy (ECT):** - Effective for very severe depression, esp. with psychotic symptoms when a rapid response is needed, or other treatments have failed - Given after general anaesthetic and muscle relaxant (not like One Flew Over the Cuckoo's Nest) - Usually involves 6-12 treatments - Rapidly effective in the short term, but risk of memory difficulties. - Mainly used in inpatient settings. - **Psychological Approaches** - [Cognitive Behavioural Therapy (CBT): ] - CBT is the first line of psychological treatment for depression (NICE). - Main premise: **thoughts, feelings and behaviours are all interlinked and affect each other.** - Attempts to address the maintenance cycle of depression by addressing unhelpful interpretations and unhelpful coping strategies. - **Behavioural Activation (BA):** - A behaviourally oriented technique used as part of a CBT approach that targets environment and behaviour - Main premise: **Context and behaviours maintain depression** - Changing behaviour can have a direct effect on thoughts and feelings - Aim to assist client to understand environmental sources of depression, and address behaviours that might maintain or worsen the depression. - **Isolation and avoidance are common targets of intervention** - [Interpersonal Therapy (IPT)]: - Brief, structured approach based on psychodynamic/attachment principles - Addresses interpersonal issues - Main premise: mental health difficulties and interpersonal problems are interrelated - Examines individuals' perceptions and expectations of relationships, and aims to improve communication and interpersonal skills http://apt.rcpsych.org/content/aptrcpsych/17/1/23/F1.large.jpg - [Third Wave CBT Approaches (e.g. Acceptance and Commitment Therapy, Compassion Focussed Therapy, Mentalisation Based CBT)] - [Short term psychodynamic therapy] **Anxiety Disorders** - Anxiety Disorders are varied but share a set of core physical symptoms - Activation of the autonomic nervous system ("fight or flight") **Common Features**: - Increased heart rate - Muscle tension - Shallow breathing - Sweating - Appetite suppression - Nausea - Prepares body for immediate action, threat management - Can become problematic when: - Perception of danger/threat is inaccurate, persistent or generalised - Associated with avoidance/safety behaviours - Worry is common in anxiety and often difficult to treat - Panic also has cognitions around fear of heart attack, stroke, collapse etc - Cognitive and physical symptoms often/usually co-occur - Physical symptoms often lead to consulting doctors about underlying physical causes. Panic often presents as a heart attack in Accident and Emergency. **Anxiety Presentation** - Anxiety is commoner than depression in the community but less often presents to services - Anxiety is less common in primary care than depression - Physical symptoms often lead to presentation to primary care physicians - Comorbidity w/ depression: - Two thirds of people with depression report anxiety, worry or panic symptoms - Social anxiety is the most common comorbidity with depression - Overlap of symptoms between depression and GAD -- insomnia, poor concentration, (& fatigue in DSM5) - Genetic evidence from twin studies for depression/GAD overlap **How Do We Treat Anxiety?** [NICE Guidelines for Anxiety Disorders] - **Pharmacological Treatment:** - Antidepressants -- SSRI, SNRI, mirtazapine are all effective. - Benzodiazepines (are addictive) - Quetiapine (antipsychotic, not used often) - Pregabalin - Propanol - **Psychological Treatment of Anxiety Disorders:** - Behavioural techniques: - Cognitive techniques: - [General Principles]: - Focus is on current maintaining factors - Maintaining factors include*:* - thoughts/beliefs - mood and physical sensations - unhelpful responses - cognitive bias towards threat - environmental stressors - [Cognitive Models and Treatment]: - Thought records - Identifying and challenging cognitive distortions/biases - Behavioural experiments - [Behavioural Models & Treatment]: (commonly used) - Relaxation training - Progressive Muscle Relaxation (PMR) - Systematic tensing and relaxation of major muscle groups of whole body - With practice, goal is to learn to become deeply relaxed rapidly - Impossible to be tense and relaxed at same time - Can implement skill when noticing that you are starting to become tense and anxious - Graded exposure - Ex. Travel phobia - Goal: To travel alone by train to the city and back 1. Travelling one stop, at a quiet time of day 2. Travelling two stops, at a quiet time of day 3. Travelling two stops, during rush hour 4. Travelling five stops, at a quiet time of day 5. Travelling five stops, during rush hour 6. Travelling all the way, at a quiet time of day 7. Travelling all the way, during rush hour **[Intellectual Disability]** ***The Normalisation Movement*** - Denmark 1959: normalisation of social indicators (Bank-Mikkelsen, 1980) - Individuals with ID should be able to live a normal life as everyone else. - Sweden 1969: normalisation of lifecycle (Nirje, 1980) - US 1972: Social Role Valorisation (Wolfensberger, 1980) - UK 1980: An Ordinary Life (King's Fund,1980) - Started a new scene of how we see people with ID. ***Policy & Theory Leading to the Present Date*** *(UK) Policy* - **2001 Valuing People:** Rights, Independence, Choice and Inclusion - **2015 -- Transforming Care:** improve health and care services better so people with LD can live in the community with support, close to home *(International) Theories/ science underpinning current service provision:* - **Person-Centred Planning:** the person with ID is at the centre of his/her life and decision making (community participation, relationships, choices, respected roles, competence development) - **Positive Behaviour Support:** applied science & practice framework that aims to improve Quality of Life (primarily) by making challenging behaviour 'inefficient and irrelevant'. ***What is Intellectual Disability? (DSM-5)*** *Three Criteria:* 1. Intellectual functioning (standardised IQ score \ - maternal infection, - maternal substance misuse, - iodine deficiency, pre-eclampsia, - ante-partum haemorrhage, - premature labour - **Intra-partum (during labour)** - prolonged labour, - trauma, asphyxia - **Neonatal (after birth)** - hypoglycaemia, - meningitis, - severe jaundice, - intraventricular haemorrhage ***Foetal Alcohol Syndrome*** - Maternal alcohol consumption during pregnancy can disrupt normal foetal development. *Range of problems:* **Physical:** - Growth restriction/low birthweight - Microcephaly - Cardiac abnormalities - Skeletal abnormalities - Poor motor skills, clumsiness **Developmental** - ID (or cognitive limitations and/or adaptive skills limitations) - Learning disabilities - Hyperactivity - Behaviour problems *Epidemiology and Co-Morbidity:* - Estimated 1-3% population meet diagnostic criteria for intellectual disability - Most not known to statutory health/social care services - ID often accompanied by other neurodevelopmental conditions - *Autism: 18% of children with ID also autistic* - *ADHD: 39% of children with ID also ADHD* - *Specific learning disorders (used to be called dyslexia, dyscalculia etc)* - People with ID have higher rates of both physical and mental ill-health compared with the general population ***Physical Health in Intellectual Disability*** - Sensory impairments - Epilepsy (roughly ¼) - Physical disabilities and mobility impairment - Respiratory disease - Gastrointestinal problems (e.g. reflux, constipation) - Acquired health problems (e.g. overweight, obesity) ***Mental Health in Intellectual Disability*** - People with intellectual disability are at a greater risk of a range of mental health conditions. - Challenging behaviour: - Not a mental health diagnosis but... - Strongly associated with mental health problems in intellectual disability - Aggression, self-injury, destruction, sexually inappropriate behaviours - More than behaviour problems - 18% prevalence - *Factors:* - Autism, abuse incl. restrictive practices, lack of stimulation or meaningful activity, lack of appropriate communication, vision impairment, male gender, younger age, severity of ID. ***Healthcare for People with ID*** - People with ID experience health inequities. - Over one-third deaths of people with ID were deemed "avoidable" *i.e.* preventable by the provision of good quality healthcare (cf. 13% general population deaths) - People with ID may be exposed to more adverse environmental conditions *e.g.* poverty, lack of opportunity, bullying, loneliness - Preventative health measures might not serve people with ID well *e.g.* public health messages unsuitable, rates of cancer screening are lower - People with ID face barriers to diagnosis and treatment -- physical barriers, systems factor, attitudinal barriers. - Diagnostic overshadowing: - Occurs when a presentation is attributed to the intellectual disability rather than a potentially treatable cause - Stigma, discrimination, lack of education, lack of skills - Can cause physical or mental illness to be overlooked which can lead to missed or delayed diagnosis and treatment and development of complications ***Seeing People with Intellectual Disability*** - Think about communication - Ensure sufficient time - Gather collateral information if possible - Make reasonable adjustments (Equality Act, 2010) - Requires training of professionals - 2023 mandatory training in the UK for *all* health and social care staff: [The Oliver McGowan Mandatory Training on Learning Disability and Autism](https://youtu.be/ouhKSOGm49g) - [http://www.gmc-uk.org/learningdisabilities/\#](http://www.gmc-uk.org/learningdisabilities/) *Adapting Communication:* - Use simple everyday language - Short, plain sentences that convey one point - Avoid metaphors and abstract terms - Give time for person to process the information and to answer - Check understanding -- repeat if needed - 'Anchor' events if difficulties with concept of time - Open questions if suggestible - Rephrase if acquiescent - Supplement with accessible written or recorded information - Might be helpful to see patient with supporter but speak to the person with intellectual disability first - Involve other professionals or techniques *Assessing Mental Health* - Principles of assessment same as people without intellectual disability - Interview - Observations - Collateral information - *Change* is significant - *Presentation of Mental Health Problems:* - People with mild ID may report typical symptoms of mental illness (e.g. low mood or hearing voices) - The more severe the ID, the more likely that you will have to rely on ***observations of behaviour*** and "biological symptoms" (e.g. changes in sleep, appetite and routine) \* - They are more likely to have "***atypical symptoms***" e.g. self-injurious behaviour or physical aggression in depression - Psychotic symptoms are usually "simple" in nature e.g. hearing sounds rather than words; may be "talked out" of a delusion *Factors that can Influence Presentation* - Severity of ID and difficulties in communication - Sensory impairment - Presence of autism -- "concrete thinking", difficulties reporting emotions - Pre-existing behaviour problems may be present -- establish what is "normal behaviour" - Some behaviours may be developmentally appropriate *Behavioural Correlates of Mental Illness (observable signs)*  *Interventions for Mental Health Problems* - *Psychotropic Medication:* - Same principles as for people without ID - Antipsychotics, mood stabilisers, anti-depressants, anxiolytics - Evidence base for psychotropic medication in people with ID is under-developed, especially for challenging behaviour - Medication can be given alone or in combination with psychosocial treatments - It is important to: - Monitor response and potential side-effects - Involve the person and their supporters - *Psychosocial:* - Many different types *e.g.* CBT, DBT, psychodynamic, psychoeducation, family therapy, art therapy - Several manualised therapies - Delivered individually or as groups - Adapted approaches and support often needed - Shorter sessions - More sessions - Use accessible materials/ visual aids - More focus on behavioural aspects - *Other treatment options:* - **Speech and Language therapy** -- communication assessment and enhancing communication (e.g. Visual timetable, social story) - **Occupational therapy** -- assessment of daily living skills and strategies to enhance independent living skills - **Nursing** -- Health Action Plans, hospital passport, monitoring mental state - *Social approaches:* - Community inclusion - Meaningful daytime activities (college, day centre) - Supported employment - Developing skills for independent living -- ***Active Support*** - Respite care for carers and carers' assessment ***Research for ID*** - Evidence base for interventions in ID is improving, but still many questions - May need to extrapolate evidence from studies conducted in non-ID population - ID is often an exclusion criterion in studies - There are additional considerations when doing research in people with intellectual disability -- think of a few... *Challenges to Research in ID:* - Some people with ID may lack capacity to consent to take part - Complex research procedures need to be explained (*e.g.* randomisation) - Different methods of recruitment are needed - 'Gatekeepers' are important - Adapting materials and the intervention - Ongoing support to maintain involvement - Consultation group with ID is important or **inclusive / collaborative** research ***Health Services for People with an ID:*** *Adults:* - **Community Learning Disability Team:** nursing, physiotherapists, speech and language therapists, occupational therapists, psychologists, psychiatrists, behaviour support specialists - **Intensive Support Services:** similar to above in many ways but focus on people whose behaviour challenges (Applied Behaviour Analysts) *Children:* - **Specialist child and adolescent mental health teams:** nursing, speech and language therapists, clinical psychology, psychiatry - **Child Development Teams:** paediatrics, speech and language therapists, occupational therapy *Challenges Accessing Services* - Joint working often needs to be improved - 'Eligibility' and falling between gaps - Difficulty in accessing crisis care - Case for "shared care" rather than dualistic thinking - Liaison with primary care and general hospitals ***Stigma*** - Labelled as different - Stereotypes and prejudice - Discrimination - Leads to exclusion, reduced self-esteem, psychological distress ( mental illness), 'self-stigma' *Specific stigmas:* - People with ID are one of the most stigmatised and excluded groups in society. - Often victims of hate crimes such as bullying and physical abuse. - Public stereotypes include people with ID not being able to work or live independently, needing to be protected or sheltered, or of posing threat/danger to the public. **[Autism ]** - Presentation depends on age, gender, and comorbidities. - A neurodevelopmental condition - Key differences: - Social communication skills - Experiences and understanding of the world - Sensory activities - Autism is NOT: - An illness or disease, not looking to cure. - Diagnostic criteria (ICD 11): - Deficits in initiating and sustaining social communication and reciprocal social interactions. - Persistent restricted, repetitive, and inflexible patterns of behaviour, interests, or activities. - Occurs during the developmental period. - Symptoms may result in significant impairment in personal, family, social, educational, occupational, or other areas of functioning. - Differences and difficulties in communication: - Social-emotional reciprocity - Non-verbal communication - Developing and maintaining relationships - Repetitive/ restricted patterns of behaviours: - Restricted and fixated interests - Repetitive speech/ motor/ use of objects - Excessive adherence to routines - Hyper or hypo reactivity to sensory output - Medical models of disability: - Focuses on the individual - Social models: - Disability community - Many different versions - Impairment: individual and private - Disability: structural and public - People are disabled by barriers in society - Autism interventions now: - Formulation and understanding; complex psychoeducation - Mental health difficulties - Emotional regulation - Low self-esteem/ self-criticism - Hx of invalidation and not being understood, stigma, bullying - Processing emotions, experiences, thoughts, and memories - The dual nature of autism: - Maximizing potential - Minimizing barriers - Optimizing the person-environment fit **[Neuropsychology]** **[Psychology in Physical Health Care]** ***Key Definitions:*** - *Acute illness/pain/injury:* Pain that lasts less than 6 months; warning sign to your body that something is unsafe, something is broken, etc. - *Chronic pain/condition:* Pain that lasts more than 6 months. - *Long-term health conditions:* Chronic conditions where there is usually no cure and managed with medications and other interventions. ***Context:*** - 16.5 million people with long term physical health conditions across the life span in England. - 15% have two or more long term conditions. - 4.5 million experience psychological distress - 2-3x more likely to experience mental health difficulties compared to general population - Increases to 7x with one or more conditions - 10-30% of children are directly or indirectly affected by physical health difficulties - 11% of children experience significant chronic illnesses that limit their daily life - 10-37% experience a psychological difficulty - This relationship between physical and psychological presentations results in £8-13 billion of the NHS budget in England spent on the population of physical health presentations. - Department of Health (2012) found that this amount accounts for 50% GP appointments, 70% bed days, 70% of acute and primary care budgets. ***What Contributes to These Increased Costs?*** - When individuals do not receive the appropriate psychological support there is a 45-75% increase in service costs regardless of medical condition. - This number stays after accounting for demographic and clinician factors. - Unnecessary medical investigations. - Frequent A&E visits and outpatient appointments. - Increase medication use and admissions. - Indirect costs such as not attending work and reduced work productivity. ***Mind and Body Dualism*** - 17^th^ Century Descartes with groundings in philosophy. - Mind and body as separate entities. - Underpins the medical model. ***Biopsychosocial Model*** *-Biological:* genetics, tissue injury/ damage, nervous system characteristics, chronic stress, etc. *-Psychological:* emotions, behaviours, coping styles, fears, beliefs of causes, experiences, attitudes and expectations. *-Social:* social expectations, environment, culture, living situations, access to healthcare, etc. ***Role of Clinical Psychologists*** - Clinical work - Individual work - Working with families and couples - Group work - Joint working with other professionals - Inpatient and outpatient work - Working with multidisciplinary teams - Consultation - Teaching, education and training - Facilitating reflective practice for medical staff - Supervision - Research and audit - Development and leadership roles ***What Models Do We Use in Physical Health?*** - Cognitive behavioural therapy - Ways people can cope with pain and deal with the changes they may be going through. - Third-wave Approaches - Compassion Focused Therapy - Acceptance and Commitment Therapy - 5 P's - Solution-Focused Approaches - Systemic approaches - Family, healthcare system, education system contributors to person's experience. ***Clinical Effectiveness of Psychological Interventions*** - Evidence-based interventions e.g. CBT and third wave therapies have been found to improve: - treatment adherence - adjustment to conditions - quality of life and coping - Some evidence that self-help interventions may improve mood in patients with physical health conditions (Matcham et., 2014) - Richard et al. (2017)'s study found that psychological interventions improved psychological symptoms and reduced cardiac mortality for those with cardiac heart disorder - Anderson and Ozakinic (2018) found that in individuals with LTCs short-, medium- and long-term psychological interventions improved quality of life - In an 8-week RCT, ACT improved psychological stress and depression in patients with Irritable Bowel Disease (Wynne et al., 2019) - A retrospective study found that psychological interventions offered in primary care predicted greater attendance at appointments and engagement with physical health care (Ricou et al., 2019) - CBT for migraine has been found to reduce migraine frequency, intensity, (Bae et al, 2021) and has also been found to be effective in treating symptoms associated with chronic pain (Eccelston, 2001) - Integrated MDT care for conditions such as Type 2 diabetes has found to improve quality of life and mood related outcomes (Diabetes UK, 2010) - The National Institute for Health and Clinical Excellence (NICE) guidelines has recommended psychological approaches be a part of recommended interventions for certain physical health conditions ***Challenges*** - Not recognizing the psychological factors that contribute to physical presentations - Focusing on just the physiological impact of conditions risk ignoring important aspects of the individual (Naylor et al., 2016) - Risk of pathologizing distress - Risk of pathologizing normal coping response to stress ***Language*** - How language is talked about in the medical model - E.g. "bad hand" and instead of using factual language - "corrective" surgery which suggests something is wrong - Using medical jargon - Acceptance-Based approach rather than Fixing-Based approach - Thinking about modelling and messages we give to service users - Consider cultural factors ***Assumptions*** - Assumptions effect and influence us all - They are subtle and often unconscious thought processes, but they have a significant impact on our perceptions.