PTSD assessment OSCE musts
Recognise from the information provided that the patient is most likely to be suffering from PTSD.
Take a salient history to confirm the diagnosis of PTSD
Establish the trauma and the patient‟s reaction to it.
Enquire about persistent re-experiencing of the trauma: intrusive memories; nightmares, psychological distress and physiological reactivity when cued to trauma
Enquire about avoidance; efforts to stop thinking or talking about trauma, avoiding: being alone in her flat, sleeping in lounge, social interactions including intimacy with her fiancé, males in general, feeling detached from others and diminished interest
Enquire about symptoms of hyper-arousal including: sleep disturbance, irritability, being on edge and startling easily.
Probe for pre-existing and secondary co-morbidities (i.e. depression, alcohol and/or substance abuse, eating disturbances, other anxiety disorders and suicidality).
Explain the nature of PTSD to the patient
Outline the key management strategies based on the evidence base for treatment of PTSD, including the relative roles of medications and trauma focused psychotherapy in an accurate and understandable manner.
Individualise explanation of the management plan to patient‟s symptoms and particular concerns.
Throughout these more specific tasks the candidate is expected to develop an adequate therapeutic alliance and be sensitive to the patient.
Judith Herman’s description of trauma
In her classic book ‘Trauma and Recovery’ Judith Herman (1992) describes trauma as events that overwhelm the ordinary adaptations to life and are characterised by terror and helplessness
This can have long-term self-perpetuating effects where the overwhelming events remain unintegrated in the psyche, damaging both one’s sense of self and relational capacities. She notes that for those whose trauma included a physiological freeze response (frozen with terror) are particularly prone to later problems. Where the trauma is from childhood, she identifies three major forms of adaptation: dissociative symptoms, a fragmented identity, and difficulty regulating emotional states
Dissociated symptoms
Dissociation is a word that is used to describe the disconnection or lack of connection between things usually associated with each other. Dissociative symptoms include depersonalisation (feeling unreal), derealisation (feeling as if the world is unreal) or blanking out.
Dissociated experiences are not integrated into the usual sense of self, resulting in discontinuities in conscious awareness (Anderson & Alexander, 1996; Frey, 2001; International Society for the Study of Dissociation, 2002; Maldonado, Butler, & Spiegel, 2002; Pascuzzi & Weber, 1997; Rauschenberger & Lynn, 1995; Simeon et al., 2001; Spiegel & Cardeña, 1991; Steinberg et al., 1990, 1993). In severe forms of dissociation, disconnection occurs in the usually integrated functions of consciousness, memory, identity, or perception. For example, someone may think about an event that was tremendously upsetting yet have no feelings about it. Clinically, this is termed emotional numbing, one of the hallmarks of post-traumatic stress disorder.
Fragmented identity is associated with an unstable changeable personality or an internal sense of fragmentation. Difficulty regulating emotional states refers to symptoms of emotional instability and reactivity.
The psychological process of dissociation is commonly found in people seeking mental health treatment (Maldonado et al., 2002). Dissociation may affect a person subjectively in the form of ‘made’ thoughts, feelings, and actions. These are thoughts or emotions seemingly coming out of nowhere, or finding oneself carrying out an action as if it were controlled by a force other than oneself (Dell, 2001). Typically, a person feels ‘taken over’ by an emotion that does not seem to makes sense at the time. Feeling suddenly, unbearably sad, without an apparent reason, and then having the sadness leave in much the same manner as it came, is an example. Or someone may find himself or herself doing something that they would not normally do but unable to stop themselves, almost as if they are being compelled to do it. This is sometimes described as the experience of being a ‘passenger’ in one’s body, rather than the driver.
There are five main ways in which the dissociation of psychological processes can change the way a person experiences living: depersonalisation, derealisation, amnesia, identity confusion, and identity alteration.
There are several types of dissociative disorders, all of which cause a change in consciousness, memory, identity, or how one views his or her surroundings. The change can come on abruptly or slowly, and it may not happen all the time
Types of dissociative disorders
- Depersonalisation / Derealisation Disorder: a person feels ‘detached from’ their thoughts or body. For example, they may feel as though they are floating outside their body, looking at people through a window, or in a dream. Despite these experiences, the person still stays in touch with reality.
- Dissociative Amnesia: where a person has one or more experience of being unable to remember or recall important information about themselves. This difficulty in remembering information goes beyond simple forgetfulness. The information that the person cannot recall is usually about some kind of traumatic or stressful event.
- Dissociative Identity Disorder: used to be called, ‘Multiple Personality Disorder’ where a person will have two or more separate identities that each have their own way of thinking and relating to the world. To have this disorder, a minimum of two of these identities must also take control over the person’s behaviour again and again. The person with dissociative identity disorder may also have difficulty remembering personal information that, like dissociative amnesia, goes beyond simple forgetfulness.
- Dissociative Disorder Not Otherwise Specified: this term is used to describe a dissociative disorder where the main feature is still some kind of dissociative experience, but criteria for other dissociative disorders are not present.
PTSD and Dissociation
Individuals with PTSD also may be more likely to have a dissociative disorder. For example, a study of 628 women from the general community found that, of those with a dissociative disorder (the most common of which was dissociative disorder not otherwise specified, followed by dissociative amnesia), 7 percent also had a PTSD diagnosis (Sar V, Akyuz G. Dogan O. (2007).
The Link Between Trauma and Dissociation
The relationship between traumatic experiences and dissociative symptoms is well-established in the literature and can be found in studies from many cultures and countries worldwide (e.g. Baita, 2006; Gingrich, 2006; Sar et al., 2014).
Depersonalisation
Depersonalisation
Depersonalisation is the sense of being detached from, or ‘not in’ one’s body. This is what is often referred to as an ‘out-of-body’ experience. However, some people report rather profound alienation from their bodies, a sense that they do not recognise themselves in the mirror, recognise their face, or simply feel not ‘connected’ to their bodies in ways which are challenging to articulate (Frey, 2001; Guralnik, Schmeidler, & Simeon, 2000; Maldonado et al., 2002; Simeon et al., 2001; Spiegel & Cardeña; Steinberg, 1995). Depersonalisation is often associated with trauma. It can sometimes present like atypical depression and is often co-morbid with it (Baker et al., 2003, p. 428). The symptoms include feeling emotionless and detached from various aspects of self (Depersonalisation Research Unit DRU, 2001, p. 128) and ‘feelings of having the mind empty of thoughts, memories or images, and an inability to focus and sustain attention’ (Sierra & Berrios, 2000, p. 154). Clients may report such things as ‘I don’t feel like a person’ or ‘Most of the time I’m feeling empty’ or ‘It’s very rarely that I can conjure up memory or emotions about the past or anything like that, because normally I can’t’.
Physiologically depersonalisation is understood as a ‘heightened arousal combined with a dampening of emotional response, [and] is widely viewed as a defence mechanism in the face of severe stress, life-threatening situations or trauma’ (DRU, 2001, p. 129). This view is shared by Sierra & Berrios who contend that depersonalisation ‘results from two simultaneous mechanisms: an inhibition of emotional processing, and a heightened state of alertness’ (2000, p. 154).
Derealisation
Derealisation is the sense of the world not being real. Some people say the world looks phony, foggy, far away, or as if seen through a veil. Some people describe seeing the world as if they are detached, or as if they were watching a movie (Steinberg, 1995).
PTSD diagnosis
Criterion A: stressor - The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)
1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.
Criterion B: intrusion symptoms - The traumatic event is persistently re-experienced in the following way(s): (one required)
1. Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may re-enact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli
Criterion C: avoidance - Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)
1. Trauma-related thoughts or feelings.
2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).
Criterion D: negative alterations in cognitions and mood - Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)
1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., ‘I am bad’, ‘The world is completely dangerous’).
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.
Criterion E: alterations in arousal and reactivity - Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)
1. Irritable or aggressive behaviour
2. Self-destructive or reckless behaviour
3. Hypervigilance
4. Exaggerated startle response
5. Problems in concentration
6. Sleep disturbance
Criterion F: duration - Persistence of symptoms (in Criteria B, C, D, and E) for more than one month.
Criterion G: functional significance - Significant symptom-related distress or functional impairment (e.g., social, occupational).
Criterion H: exclusion - Disturbance is not due to medication, substance use, or other illness.
Specify if: With dissociative symptoms.
In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:
1. Depersonalisation: experience of being an outside observer of or detached from oneself (e.g., feeling as if ‘this is not happening to me’ or one were in a dream).
2. Derealisation: experience of unreality, distance, or distortion (e.g., ’things are not real’).
Specify if: With delayed expression.
Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.
Differential diagnosis
- PTSD
- Major Depressive Disorder
- Dissociative Disorder NOS
- Panic Disorder
- Anxiety Disorder NOS
- Borderline Personality Disorder
Brief overview management
Presents either trauma–focused therapy (cognitive behaviour therapy OR eye movement desensitisation reprocessing (EMDR) together with in vivo exposure to avoided situations) as an effective treatment.
Briefly, covers the key aspects of therapy for PTSD i.e. stress management (e.g. relaxation training, controlled breathing, adaptive coping statements, thought stopping and distraction techniques), graded exposure to the trauma memory as well as imaginal and in vivo exposure to avoided situations, cognitive processing of the interpretations of the trauma, and possible involvement of significant others.
Describes the role of medications as secondary but may suggest medication changes such as: increase in dose of paroxetine, switching to an alternative antidepressant (e.g. SSRI, newer generation antidepressant or tricyclic). Considering the hypnotic is aware of relative contraindication long-term except where use is intermittent
understand impact of comorbid conditions & explains how PTSD leads to depression and/or alcohol dependence; aware of importance of marital issues & skilfully incorporates in management of other conditions; able to incorporate factors such as lifestyle factors, age appropriate community activities in management plan.
The plan should be conveyed to the patient in suitable language. The patient should be asked if they understand and agree with the plan. Communication with the GP and/or obtaining a collateral history is desirable.
Explanation regarding chronic nature of PTSD & impact of symptoms on daily functioning.
Biological treatments eg level one evidence for SSRIs but other antidepressants can also be helpful. Other medications may include antipsychotics, hypnotics, medications for nightmares (prazosin,topiramate)
Psychological management eg CBT, trauma focused work, imaginal exposure, psychotherapy, relaxation, graded exposure, restructuring of traumatic memories, EMDR (eye movement desensitisation).
Social support groups, attendance at community or veterans activities. Involvement and education of wife in treatment.
Management in PTSD with depression alcohol and marital problems
Alcohol
Explanation about the impact of alcohol use (on mood/marriage/physical health) & need to reduce consumption.
Risks of withdrawal. Need for physical investigations eg liver function tests.
Biological treatments: Naltrexone/acamprosate +/- antidepressants. Thiamine. Short term BZP for withdrawal.
Social treatments: eg abstinence vs controlled drinking; AA; drug & alcohol counselling; include wife in treatment
Depression
Explanation of impact of depression & depressive symptoms; investigation for causes eg thyroid function, anaemia
Biological treatments eg classes of antidepressants. Short term sedative for insomnia.
Psychological management eg CBT, group therapy, psychotherapy.
Inclusion of wife in education and management. Social options such as support groups.
PTSD
Explanation regarding chronic nature of PTSD & impact of symptoms on daily functioning.
Biological treatments eg level one evidence for SSRIs but other antidepressants can also be helpful.
Psychological management eg CBT, imaginal exposure, psychotherapy, relaxation, graded exposure, restructuring of traumatic memories, EMDR (eye movement desensitisation).
Social support groups, attendance at community or veterans activities. Involvement and education of wife in treatment.
Marital conflict.
Explanation of impact on wife & need to involve her in aspects of future treatment; offer to meet with her & explore her perspective; offer education to her about complexity of diagnoses & PTSD symptoms interfering with intimate relationships.
Possible couple therapy to air/explore each partners’ views/wishes; Social groups where both can feel comfortable.
Purpose of exposure therapy
The goal is to activate the fear by introducing the feared stimuli so that a person has the opportunity to learn that:
- Being in a safe situation that reminds them of the trauma is not dangerous
- Remembering the trauma is not the same as reliving it
- Anxiety can decrease (without avoidance)
- Experiencing symptoms of PTSD does not necessarily lead to a loss of control.
Comprehensive assessment of PTSD
A thorough assessment is required, covering PTSD and related diagnoses, quality of life and psychosocial functioning, trauma history, general psychiatric status (noting extent of comorbidity), physical health, substance use, relationships and family situation, and vocational and social status. Assessment should include assessment of strengths and resilience.
Assessment and intervention must be considered in the context of the time that has elapsed since the traumatic event occurred. Assessment needs to recognise that whereas the majority of people will display distress in the initial weeks after trauma exposure, most of these reactions will remit within the following three months.
Assessment and monitoring should be undertaken throughout treatment. When adequate progress in treatment is not being made, the practitioner should revisit the case formulation, reassess potential treatment obstacles and implement appropriate strategies
Psychological interventions for adults with PTSD
Adults with PTSD should be provided with trauma-focussed interventions (trauma-focussed cognitive behavioural therapy [CBT] or eye movement desensitization [EMDR] and reprocessing, in addition to in vivo exposure). As available evidence does not support the importance of eye movements per se in EMDR, it is recommended that practitioners who use EMDR be aware that treatment gains are more likely to be due to the engagement with the traumatic memory, cognitive processing and rehearsal of coping and mastery responses. Following diagnosis, assessment and treatment planning, 8–12 sessions of trauma-focussed treatment is usually sufficient.
Where symptoms have not responded to one form of first line trauma-focussed interventions (trauma-focussed CBT or EMDR in addition to in vivo exposure), health practitioners may consider the alternative form of trauma-focussed interventions. Non trauma-focussed interventions such as supportive counselling and relaxation should not be provided to adults with PTSD in preference to trauma-focussed interventions.
Where symptoms have not responded to a range of trauma-focussed interventions, evidence-based non trauma-focussed interventions (such as stress management) and/or pharmacotherapy should be considered. Sessions that involve imaginal exposure require 90 minutes to ensure that therapy is adequate in those sessions. For PTSD sufferers with several problems arising from multiple traumatic events, traumatic bereavement, or where PTSD is chronic and associated with significant disability and comorbidity, further sessions using specific treatments to address those problems may be required. Where adults have developed PTSD and associated features following exposure to prolonged and/or repeated traumatic events, more time to establish a trusting therapeutic alliance, more attention to teaching emotional regulation skills and a more gradual approach to exposure therapy may be required. Individual and group psychological interventions Group CBT (trauma-focussed or non trauma-focussed) may be provided as adjunctive to, but should not be considered an alternative to, individual therapy.
Pharmacological interventions for adults with PTSD
Drug treatments for PTSD should not be used as a routine first-line treatment for adults, either by general practitioners or by specialist mental health professionals, in preference to a trauma-focussed psychological therapy. Where medication is considered for the treatment of PTSD in adults, selective serotonin reuptake inhibitors (SSRI) antidepressants should be the first choice for both general practitioners and mental health specialists.
Other new generation antidepressants (notably mirtazapine) and the older tricyclic antidepressants should be considered as a second-line option. Phenelzine can be considered for use by mental health specialists for people with treatment resistant symptoms.
Antidepressant medication should be considered for the treatment of PTSD in adults when:
the patient is unwilling to engage in trauma-focussed psychological treatment
the patient is not sufficiently stable to commence trauma-focussed psychological treatment (as a result, for example, of being actively suicidal or homicidal, or of severe ongoing life stress such as domestic violence)
the patient has not gained significant benefit from trauma-focussed psychological treatment
the patient is experiencing a high level of dissociative symptoms that are likely to be significantly exacerbated by trauma-focussed therapy.
Antidepressant medication should also be considered as an adjunct to psychological treatment in adults where core PTSD symptoms are of sufficient severity to significantly interfere with the sufferers’ ability to benefit from psychological treatment.
Where a decision has been made to commence pharmacotherapy, the person’s mental state should be regularly monitored with a view to commencing adjunctive psychological treatment if/when appropriate. In the interim, supportive psychotherapy with a substantial psychoeducational component should be offered.
Where significant sleep disturbance or excessive distress does not settle in response to reassurance, simple psychological first aid, or other non-drug intervention, cautious use of hypnotic medication may be appropriate in the short term. If the sleep disturbance is of more than one-month duration and medication is likely to be of benefit in the management of the person’s PTSD, a suitable antidepressant should be considered. The risk of tolerance and dependence are relative contraindications to the use of hypnotics for more than one month except if their use is intermittent.
Where symptoms have not responded adequately to pharmacotherapy, consideration should be given to:
increasing the dosage within approved limits
switching to an alternative antidepressant medication
adding risperidone or olanzapine as an adjunctive medication (recognising these are off-label uses)
considering the potential for psychological intervention.
Adult PTSD patients receiving pharmacotherapy should be seen at least weekly if there is a significant risk of suicide; if there is no significant risk of suicide, fortnightly contact is recommended initially, dropping to less frequent after three months if the response is good. When an adult patient with PTSD has responded to medication, it should be continued for at least 12 months before gradual withdrawal
Trauma-focussed Cognitive Behavioural Therapy (TF-CBT) – Grade A:
The two core interventions of TF-CBT for PTSD are exposure, and cognitive restructuring. TF-CBT is a short-term intervention that generally lasts anywhere from eight to 25 sessions, and these structured psychological interventions aim to address the emotional, cognitive and behavioural sequelae of exposure to traumatic events. It has been shown to be superior to therapies which do not involve talking about the trauma – creating the trauma narrative - and it is as e-ffective as other evidence-based therapies for PTSD such as Eye Movement Desensitisation and Reprocessing (EMDR). A common approach, for example, would be to use exposure alongside psychoeducation, anxiety management, cognitive restructuring and relapse prevention to treat PTSD.
Desensitisation / graded exposure is a core component of TF-CBT. Controlled and planned exposure to the trauma narrative, and reminders of the trauma or emotions associated with the trauma, are used to help the patient reduce avoidance and maladaptive associations with the trauma. Discussing the trauma or going through exposure exercises may trigger intense emotions or bring up memories of the trauma that are particularly difficult. It is crucial to undertake TF-CBT in the context of a safe, stable, and supportive environment.
Eye Movement Desensitisation and Reprocessing (EMDR) – Grade A:
EMDR, a treatment for PTSD was developed by Shapiro in the late 1980’s. EMDR is based on the assumption that, during a traumatic event, overwhelming emotions or dissociative processes may interfere with information processing. This leads to the experience being stored in an unprocessed way, disconnected from existing memory networks.
Although the exact mechanism of action of EMDR is not well understood, in EMDR the person is asked to focus on trauma-related imagery, negative thoughts, emotions, and body sensations while simultaneously moving their eyes back and forth following the movement of the therapist fingers across their field of vision for 20-30seconds or more. This process may be repeated many times. It is proposed that this dual attention facilitates the processing of the traumatic memory into existing knowledge networks, although the precise mechanism involved is not known. The unique feature of EMDR is the use of eye movements as a core and fundamental component throughout treatment.
Therapy commences with history taking of the specific problem and associated symptoms and behaviours, from which specific treatment targets for EMDR are developed. These targets include the event(s) from the past that created the problem, the present situations that cause distress, and the key skills or behaviours the patient needs to learn to move forward. Detailed in-depth discussion of disturbing memories is not required at this stage. In the next phase of therapy, the patient is taught specific techniques to rapidly deal with emotional disturbances that may arise. At the same time the therapist outlines the theory of EMDR.
The therapist then identifies the aspects of the target to be processed, and the patient selects a specific picture or scene from the target event that best represents the memory. A statement is chosen that expresses a negative self-belief associated with the event, and another more appropriate positive self-statement is identified that represents what the patient would rather believe. Ratings of distress are used as a measure of improvement as the targeted event changes and its disturbing elements are resolved. During desensitisation, the therapist will lead the person in sets of eye movement (or other forms of stimulation) with appropriate shifts and changes of focus until the level of distress is zero. During treatment more positive cognitions are strengthened and installed. The goal is to concentrate on and increase the strength of these positive beliefs that the person has identified to replace the original negative beliefs.
Based on evidence that indicate a physical response to unresolved thoughts (often referred to as motoric memory) successful therapy should also enable a patient to bring up the original target without feeling bodily tension. Each session should end with the person feeling in control. If the processing of the traumatic target event is not complete at the end of the session, the therapist must assist the person to apply a variety of self-calming techniques in order to regain a sense of balance. As with any form of good therapy, it is important to determine the success of the treatment over time.
Exposure therapy
The key objective of exposure therapy is to help the person confront the object of their anxieties. The notion that if people can be kept in contact with the anxiety provoking stimulus for long enough, they’re anxiety will inevitably reduce. Exposure therapy for PTSD involves confronting the memory of traumatic experiences in a controlled and safe environment (imaginal exposure), as well as confronting trauma -related avoided situations and activities through in viable exposure. The importance of grading the exposure, often using a hierarchy, prolonging the exposure until the anxiety has reduced and repeating the exposure item until it evokes minimal, anxiety are central to traditional exposure approaches.
Prolonged exposure works on the idea is that facing up to the memory in a planned way will lead to reduction of the negative emotions connected to the memory - so that remembering or being reminded is not associated with distress. When the memory or reminders are less distressing, the person does not have to avoid them and can have a more normal life.
Cognitive therapy:
In the treatment of PTSD, cognitive therapy helps the individual to identify, challenge and modify any biased or distorted thoughts and memories of the traumatic experience, as well as any subsequent maladaptive or unhelpful beliefs about themselves, and the world that they may have developed.
Cognitive processing therapy:
This is a particular form of cognitive therapy, refined specifically for the treatment of PTSD. Treatment focusses mainly on identifying unrealistic and unhelpful thoughts a person has about the trauma. It helps the person challenge the unhelpful thoughts and beliefs, and replace them with a rational alternative in an adaptation of standard cognitive therapy approaches. It is a 12-session cognitive behavioural manual lies treatment for PTSD that systematically addresses key post-traumatic teams, including safety, trust, power and control, self-esteem and intimacy.
Group therapy
This is not an intervention per se, but a vehicle for delivering an intervention. They have included supportive, psychodynamic, cognitive behavioural approaches (including exposure, cognitive processing therapy, problem solving). The presence of other individuals with similar experiences may help overcome a belief that the therapist cannot be helpful because he or she has not experienced the specific trauma. The group may also be used to promote a non-judgemental approach towards behaviour required for survival during the traumatic event.
Brief psychodynamic psychotherapy:
Psychodynamic therapy encourages the individual to use the supportive relationship with a therapist, and the transference that occurs within that relationship, to verbalise and reflect upon their experiences. This process allows unconsciously held thoughts, urges and emotions to be brought into conscious awareness, which in turn allows the cognitive, emotional and social aspects of experience to be integrated into a meaningful structure that helps the person to accept and adapt to their experiences.
Brief psychodynamic therapy focusses on the emotional conflicts caused by a specific traumatic event. The patient is encouraged to put their experience into words, and examine the meaning that the event and surrounding circumstances holds for them. Through this retelling, the therapist assists the individual to integrate the event and re-establish a sense of purpose and meaning in life
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Attachment8
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FFT / USM Report0
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Preparing Psychiatric Report- Not USM/FFT4
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Forensic-ethical14
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Antisocial Personality Disorder2
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Rural psychiatry position statement 6511
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Rural psychiatry- professional and ethical issues5
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Boundary violations and ethical considerations18
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Medically unexplained symptoms4
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Consultancy thinking, CANMEDS approach9
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Perinatal1
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Treatment resistant depression6
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SSRIs and side effects15
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ECT19
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Psychoeducation30
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Anxiety disorders treatment guidelines43
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First episode psychosis guidelines0
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Bipolar affective disorder0
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Lithium23
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Old age mood25
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Mood guidelines126
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Trainee burnout13
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MS and depression20
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Hepatitis and depression11
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Generalised anxiety disorder26
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Panic disorder15
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Treatment non-adherence1
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Gender identity18
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OCD20
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Social anxiety disorder16
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Body dysmorphic disorder15
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Illness anxiety disorder15
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Transcultural issues in the identification and management of mental disorders6
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Adult ADHD12
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Benzodiazepine dependence1
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Service development and allocation of resources4
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Management of pt suicide5
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Genetic testing in psychiatry4
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Self harm in adolescents6
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OTP87
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Schizophrenia guidelines46
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First episode psychosis guidelines22
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Nicotine dependence9
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MSE10
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Encoporesis0
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Delusional jealousy3
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Scholar1
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Old age13
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Epilepsy and psychosis11
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Substance use disorders1
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Psychiatric emergencies4
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ASD21
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Lewy body dementia9
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School refusal8
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Anorexia nervosa18
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Capacity3
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Research8
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Cultural formulation9
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Discharge against medical advice1
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Intellectual disability5
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PTSD33
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Gambling9
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Motivational interviewing10
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Recovery model4
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Ethical and professional issues3
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Stigma0
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Tourettes12
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Critical incident management19
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Sexual offending6
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Assessment and treatment of sexually abnormal behaviour20
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A guide to clinical ethics in psychiatry14
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Mock exam theme44
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Alternative to acute admission30
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Adolescent forensic psychiatry38
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rTMS7
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Fetal alcohol spectrum disorder1
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Mnemonics5
