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Plenary review

Depression is different to sadness because it is more severe, lasts longer and may be due to no apparent cause.

  • Interview with Nic
  • Plenary scenario - David
  • School test results (NAPLAN).
  • David didn’t do well in the Year 9 National Assessment tests (NAPLAN), scoring in band 9 for all three tests (reading, language conventions, numeracy). The national minimum expected is band 6, but David’s best friends all gained band 10 or above.
  • He is really upset as he has achieved good results at secondary school and has done better than his peers in most schoolwork assessments during year 8.

Answer the following questions:

  • 1. What is the stressor in this case?
  • 2. List the factors likely to affect David’s responses to this disappointment.
    • Doing badly in exams
  • 3. What were David’s expectations here? Why is this important?
    • Expected to do better than his friends (from past), but did worse, so it compounded his stress levels
  • 4. How stressful would this be for you on a scale of 1-10 (10 being unbearable)?
    • Over 9000
  • 5. How might you respond in the same situation?
    • Individual variation, people should talk to friends and then motivate themselves to improve
  • 6. What was David’s response?
    • Got really upset, couldn't cope.
  • 7. What contributing factors were there?
  • 8. Would male and female students respond differently and why?
    • Females talk to friends and stuff more; more touchy feely.
  • Similarities between David and Nic:
    • Family history
    • Transitional period in life
    • Diseased siblings (less attention)
  • Differences:
    • David doesn't have the highs
  • What more information is needed to understand every symptom?
    • Suicidal thoughts, self harm
    • Any ongoing problems that could cause normal sadness to last a long time
    • Triggers

David

  • David was a high achiever and had wanted to be a doctor since he was 9 years old.

David’s early stressors

  • When he was 12, David’s parents went through a bitter divorce.
  • During the divorce David developed a low mood but still enjoyed activities at school.
  • David decided to live with his father and new stepmother, while his sister lived with their mother.

Family history

  • After the divorce, David’s mother was prescribed anti- depressants. He was aware his sister and uncle had problems with their mood too.

David’s stressors at 13

  • David’s new family was very supportive until the birth of his new step brother – William, who was born with Down Syndrome.
  • David felt cast aside and isolated. He felt that he was in the way.

David’s coping strategies

  • David’s low mood returned but he took refuge in his schoolwork and going out with friends.
  • Eventually life returned to normal.

David’s stressors at 15

  • In year 9 school tests (NAPLAN), David got low marks in science subjects which he found devastating .
  • He felt unsupported at home as his dad and step-mum were distracted by William’s special needs.
  • David wanted to go and live with his mum and sister but his mum said no.
  • David felt very isolated.

David’s mood change

  • Nothing would lift his David’s low mood
  • His body felt leadened
  • He found he had low energy and little interest in his normal activities
  • He withdrew from his friends
  • David’s grades started slipping
  • He felt unworthy of medical school
  • David lost all motivation.

How can David access medical help?

  • David started staying in bed all day feeling hopeless instead of going to school.
  • One day David googled “teenage sadness” on the net.
  • From the information he found he realised his problem was more than just sadness and that he needed some help.
  • He didn’t really know where to get help and was reluctant to ask.
  • The last thing he wanted to do was see a GP.

Epidemiological data from plenary

  • Lifetime rates of unipolar depression (major depressive disorder and dysthymia) reach adult rates of 20%-25% by 18 years of age.
  • In Australia, the 1995 National Survey of Mental Health and Wellbeing found a prevalence of 27% mental disorders for those in the 18–24-year age range.
  • 50% of all life-long psychiatric disorders start by 14 years of age, and 75% by 24 years of age.
  • Peak age of first onset of affective disorders is typically 15– 19 years.
  • Up to to 60% of adults with major depressive disorder or bipolar disorder experiencing their first mood symptoms before age 21.

As diagnosed from wikipedia:Diagnostic and Statistical Manual of Mental Disorders

Own scenario

  • Summary of possible factors that affect individual response to stress for situations discussed:
    a) Are the differences portrayed in response to stress in David’s case and your made-up scenarios actually due to stress and how it is handled?
    b) How much is nature? How much is nurture?
    c) How to measure stress?
  • In light of the reading / preparation for this SGS: COGNITIVE MODEL:
    • 1. What do the following terms mean?
    a. Core beliefs
    b. Important events
    c. Assumptions
    • 2. Think of some examples to illustrate them using David’s scenario from the previous activity. You might have to use some artistic licence here! List these / map these on the whiteboard.
    a. Core beliefs
    b. Important events
    c. Assumptions
    • 3. Now with this information consider David’s exam stress. Can the students follow David’s response through this model?
    • 4. Can you think of some behavioural responses / emotional responses / somatic responses that David might express following this stress related to the exam result?
  • Finding out more about the elements of the cognitive model by trying out the therapy activities in “Think Good, Feel Good” (15 mins).
    • 1. Split into 3 groups to cover the following elements of the cognitive model:
    (i) Thoughts – “The Thought Tracker”
    (ii) Feelings – “The Feelings Finder”
    (iii) Controllingfeelings–“TheGoGetter”
    • 2. Divide up the activities provided on the forms for your group, so that you cover all of the activities provided if possible
    • 3. Tackle these first as individuals but then talk together as a group about what you have done and how you answered the questions and what you think that you learned from the process
    • 4. Come back to the whole group to discuss the following for your element (5 mins):
    a) What did you learn from the process that you undertook? Each group should explain their element to the others
    b) How does this element fit in the cognitive model?
    c) How might this help a child undergoing cognitive behavioural therapy (CBT)?
    d) Would this work well for an older teenager/ young adult? What might need to be changed?
  • Maintaining your well-being (15 mins): This activity will introduce some further concepts about how people can cope with stress and maintain well- being. It will also allow them some hands on experience with a different intervention – this time designed specifically for young adults: these are called “coping cards” and were designed by St Vincent’s Hospital Consultation Psychiatry Team led by Prof. Kay Wilhelm.
    • 1. Read the information sheet and take a look at the coping cards
    • 2. Choose one or two cards that are interesting to you and take a minute or so to consider them and how you or another young person might make use of them in their own life. Discuss this with a neighbour.
    a. What sort of stress is this card tackling?
    b. What method is it using - i.e. is it problem solving, emotional coping, cognitive model (e.g. challenging core beliefs or thinking), positive psychology, mindfulness, or a meditation technique?
    • 3. Would these cards be useful for young people under stress?
  • Note: There is a trial that students can participate in – see the handout for further details.

Coping Cards Introduction Hand-out Sheet

Well-Being

  • Popular use of the term ‘well-being’ usually relates to health. A doctor's surgery may run a ‘Women's Well- being Clinic’, for example. Philosophical use is broader, but related, and amounts to the notion of how well a person's life is going for that person. A person's well-being is what is ‘good for’ them. Health, then, might be said to be a constituent of my well-being, but it is not plausibly taken to be all that matters for my well-being.

Coping

  • Coping has been defined as cognitive and behavioural efforts to manage specific external and/or internal demands that are exceeding the resources of the person.
  • Coping is thus expending conscious effort to solve personal and interpersonal problems and seeking to master, minimise or tolerate stress or conflict. Psychological coping mechanisms are commonly termed coping strategies or coping skills. These may be adaptive (i.e., promoting resolution of the problem) or maladaptive (providing some relief but overall, making the situation worse e.g., getting drunk).
  • Coping styles can also be categorised as problem–focussed (e.g., problem solving, goal setting, seeking information), emotion-focussed (e.g., practising relaxation strategies, talking over with friends) and avoidant (e.g., ignoring the problem, taking drugs).

Resilience

  • Resilience refers to the idea of an individual's tendency to cope adaptively with stress and adversity. Here, coping may result in the individual “bouncing back” to a previous state of normal functioning, or using the experience of exposure to adversity to function better than expected (much like an inoculation gives one the capacity to cope well with future exposure to disease).

Coping Cards

  • The recent Clinical Practice Guidelines for Depression in adolescents and young adults note the importance of building resilience and promoting help-seeking.
  • Coping skills required for developing emotional literacy and emotional regulation are important to mental health.
  • The Coping Cards have been devised by Prof Kay Wilhelm, in the Consultation Liaison Psychiatry Team at St Vincent’s Hospital to enhance adaptive/successful coping and emotional regulation. These cards have been used for people with medical illness who found them helpful

A current study is using the coping cards to test and evaluate its effectiveness as a tool in young people. The researchers are also interested in which cards young people would prefer and were most likely to *find helpful. If young people find these coping cards helpful, they could be utilised as a brief intervention tool.

  • The coping cards are specially designed to teach the participants coping skills that may be helpful in managing stressful and anxious situations. The cards are based on evidence-based practices, including problem solving, emotional coping, positive psychology, mindfulness, and meditation techniques.
  • UNSW undergraduate medical students in the early years of the course who would like to participate in this coping cards study will be invited to complete self-report measures of distress, positive and negative feelings, coping and behavioural factors. They will be asked to assess the cards and choose 3 they would like to use, along with lifestyle enhancement tips for 2 weeks. After that the self-report measures will be repeated.
  • Participants can complete feedback on paper, online, or using smart phone application.
  • The benefit of this exercise is that it may assist young people with their own stress management with a ‘hands on’ experience. It is particularly important for medical students to practice appropriate coping skills they can use when needed. It is important that medical students lay the foundations for healthy lifestyle and adaptive coping both for their own emotional health and as it has been demonstrated that doctors’ own health-related behaviours have a significant effect on how and what they emphasise in counselling their patients.
  • Participants will be given feedback on their scores on the measures and there will be a discussion of how these measures can be used with young people in medical practice.

Wrap up discussion

  • a. What is stress in the context of the teenager / young adult?
  • b. How is stress different to mental illness?
  • c. How are people affected differently by stress?
  • d. Sum up “in a nutshell” how cognitive behavioural therapy works:
  • e. How does the cognitive model contribute to your understanding of stress and development of poor outcomes to stressful situations?

Cognitive model

  1. Core beliefs form during childhood by experiences
  2. Important events activate core beliefs
  3. Core beliefs/cognitive schemes trigger cognitive assumptions
  4. Assumptions produce automatic thoughts
  5. Automatic thoughts generate responses: Emotional, behavioural, somatic
  • Core Belief = these are fixed statements/ideas that we have about ourselves
    • Developed from an early experiences and parenting. Can be rational or irrational. Can be quite fairly fixed and rigid ways of thinking. core beliefs affect the way we think and judge all our experiences
  • Important events = stressful experiences. Note as we found above, experiences can have a different impact for every individual
  • Assumptions developed from core beliefs these can be responsible for sometimes quite right beliefs.

Applying these terms:

  • Think of some examples to illustrate these 3 terms using david's scenario from the previous activity
  • You might have to use some artistic licence here. List these/map these on the white board.
  • Now with this information consider david's exam stress. Can you follow david's response through this model?

Cognitive behaviour therapy

Scenario 3 Alternate case

  • This case will be based on Amanda, David’s older sister who lives with their mother in Goulburn, NSW. The case answers will need to be presented in SGS 12 and 13, after discussion online as for the previous alternate cases.
  • Preparation task for SGS 12
    • In SGS 12 we will look at the external influences that contribute to the risk of depression.
  • Students should form 3 groups as follows:
  • Group 1 (5 students): Epidemiology.
    • Sources:
    • Download the following from the AIHW webpage:
    • ‘Young Australians: their health and wellbeing 2007’ by the Australian Institute of Health and Welfare: http://www.aihw.gov.au/publication-detail/?id=6442467991
    • Download - Part 2 Health Status and Outcomes
    • Read Section 2.3 Health conditions. Burden of disease and injury. Read the section on mental health - pp22-26 (stopping at Health service use for mental health disorders – unless you want to read further, of course).
  • Question: How common is depression in adolescence?
  • Examine the epidemiology of teenage depression in more detail: Prevalence, age of onset – worldwide and Australia. To answer this question you should:
  • Make a table of the key prevalence rates of mental illness in young people, noting the source of the data.
  • Put this in PPT slide(s) to show your SG in SGS12.
  • Include information on:
    • Lifetime risk
    • Prevalence
    • Age effects
  • Group 2 (4-5 students): Burden of disease of depression.
    • Sources:
    • Download the following from the AIHW webpage:
    • ‘Young Australians: their health and wellbeing 2007’ by the Australian Institute of Health and Welfare: http://www.aihw.gov.au/publication-detail/?id=6442467991
    • Download - Part 2 Health Status and Wellbeing
    • Read - pp18- 22 including the Section2.3 on Health conditions. Burden of disease and injury
    • Concentrating on mental health conditions: – What do you understand from the Tables 2.4 and 2.5 and associated text regarding the burden of psychiatric disease compared to other health conditions in young people?
    • List the key points that you find here in PPT slide(s) to explain this to your peers in SGS12
    • Question: What is the burden of depression worldwide and in Australia?
    • You will need to examine the burden of mental illness in more detail – worldwide and in Australia.
    • To achieve this you will need to examine the following:
      • Age-adjusted global prevalence of depression
      • Examine the leading causes of disability worldwide and in Australia
    • Group 3 (Scenario 3 Case group = 4-5 students): Risk factors for depression in young people: Sources: Use the Adelaide Technology Health Assessment systematic review- Risk Factors Review::
      • 1. Family history and environment, Risk Factors Review: pp. 108-130;
      • 2. Stressful life events
      • a. Life Events, Risk Factors Review: pp. 99-103;
      • b. Bullying (1 student): Download and read the following: Fekkes, M., Pijpers, F.I.M., Verloove- Vanhorick, S.P. (2004). Bullying behavior and associations with psychosomatic complaints and depression in victims. Journal of Pediatrics, 144(1), 17-22. http://www.jpeds.com/article/S0022-3476(03)00610-3/abstract
      • 3. Drugs and alcohol, Risk Factors Review: pp. 89-97;
      • 4. Health problems and sleeping, Risk Factors Review: pp. 67-71.
    • Question: What are the major risk factors for depression in teenagers?
      • Examine some of the genetic and non-genetic risk factors that might lead to depression in young people.
      • On reading your extract/ paper consider the points below with your group and make a concise summary in max. 10 PPT slides to show and discuss with your peers in SGS 12. You need not have all the answers to questions (iii) and (iv), but be prepared to lead the whole class discussion.
      • (i) Identify the key risk factors for depression in adolescence.
      • (ii) How much extra risk does each of these factors contribute to an individual’s risk of developing depression?
      • (iii) Why do you think the factors you have identified contribute to depression in this age group?
      • (iv) How might teenagers differ in susceptibility to certain risk factors compared to adults?
      • (v) Using a mind map show the major risk factors for developing depression for Amanda’s scenario case –prepare this in advance but draw this up on the whiteboard in the class by leading the others to work it out.

Old notes

SCENARIO PLENARY

Life and stress

  • Normal moods
  • Stress
  • Response to stressful events
  • Factors that affect response to stress

LIFE’S UPS AND DOWNS: WHAT IS HAPPENING IN EVERYDAY LIFE?


The main factors affecting the response to stress

  • Genetics
  • Previous and early life adversity and insults on immune and/or stress systems can have long lasting effects
  • Learned responses
  • Personality
  • Coping repertoire

Toddler separated from parents. Alex left with neighbours. List factors likely to affect the child’s responses to his abandonment.

  • Attachment to parents and Catherine
  • Anxiety about Catherine’s condition
  • Personality – neuroticism
  • Temperament
  • Past experience
  • Relationship with the neighbours
  • Duration of abandonment

David received poor exam results. List the factors likely to affect David’s responses to this disappointment.

  • Genetic background
  • Personality
  • Temperament
  • Coping skills (inappropriate)
  • Familial/social network
  • High achiever (perfectionist)


LIFE’S UPS AND DOWNS: HOW DO WE RESPOND? You are stood up by your date: what possible explanations are there? You get a P+ in the assignment: what possible explanations are there?

Causes

Stable

Unstable

Internal Unattractive
  • Turning up at the wrong place
  • Upset the date, bad hair day, bad 
breath, pimple
External *Not a nice other person
  • Other person forgot
  • Other person stressed

Causes

Stable Unstable
Internal Naturally smart
  • I worked very hard
  • Easy assignment
External Course is very easy
  • Easy marker
  • I got some help

Attribution style

  • The internal-­‐external dimension refers to whether an individual attributes causes of an 
event to internal factors (self-­‐blame) or to external/situational factors
  • Causes can vary along a stable-­‐unstable dimension (alternatively called 
transient/permanent), which determined whether the individual perceives the cause as 
likely to change or as a fixed and unchangeable transient or permanent situation
  • Attribution style is linked to vulnerability to mood changes that may lead o major depressive 
disorder 
Behavioural (problem-­‐solving) response versus emotional-­‐based responses to life events. 
What would be the likely emotional and behavioural responses associated with each of the different attributional styles?
  • Emotional response – situation perceived as unchangeable o Internal, Stable 
o External, Stable
  • Problem-­‐solving response – situation perceived as changeable 
o Internal, Unstable o External, Unstable 
∍∍Is there a link between attributional style and emotional and behavioural response? Yes, see above. 
Which attribution and coping styles in response to good and bad events might be associated with the development of major depressive disorder?
  • Development of a major depressive disorder
    • Good events
      • External stable and unstable: attributes positive outcomes to others
    • Bad events
      • Internal stable and unstable: internalises blame
  • Women are more likely to experience depression
    • However,rates of male depression may be severely under-reported
  • Suicide
  • More male deaths due to suicide, 4:1; but women have more attempts
      • Men more likely to use violent methods (hanging, shooting: more effective)
      • Women more often use poisoning/overdose methods and thus are more likely to be saved
    • Women more touchy-feely and thus more likely to talk to someone/seek help
      • May explain why higher rates of depression in women (more reported)
  • Reasons for differences: social/genetic conditioning

Scenarios

  • Toddler separated from parents
    • No difference, m/f behave the same way
    • Unsettled/upset due to context and developmental stage rather than gender
  • Failing a maths exam
    • Male–blame others, female–blames elf

Attributional styles

  • Definition – the way in which an individual accounts for how things happen to them
    • Internal/external–self/non-self
    • Stable/unstable - permanent/transient situation
    • The more stable/internal thinking, the higher risk of depression