V+R revision May 2022

Presenting Problem - initial reason for which a person needs help

Predisposing Factors - why the person is vulnerable to the problem 

Precipitating Factors - triggers 

Perpetuating Factors - which keep problems going 

Protective Factors - skills, strengths, resources, support 

Cross sectional formulation explores the interactions between a situation, thoughts, emotions, body sensations, and behaviors

SMART 

Specific

Measurable

Achievable 

Relevant 

Time-bound 

0 - totally calm, relaxed 

1 - alert and awake, concentrating well 

2 - a tiny amount of tension, anxiety 

3 - mild distress, no interference on the performance 

4 - moderate distress, uncomfortable but continue to perform 

5 - quite unpleasant, interfering with performance 

6 - very uncomfortable, cannot concentrate, wants to escape 

7 - extremely uncomfortable, have to leave the situation 

8 - highest distress that was ever felt 

Visceral pain - injuries or damage to internal organs. 

Description: pressure, aching, squeezing, cramping

Somatic pain - well-localized tissue pain (muscles, joints, bones) 

Description: aching, gnawing, throbbing, or cramping

Neuropathic pain - damage or dysfunction of the nervous system 

Description: shooting, burning 

• Bio (physiological pathology)
• Psycho (thoughts emotions and behaviors such as psychological distress, fear/avoidance beliefs, current coping methods and attribution)
• Social (socio-economical, socio-environmental, and cultural factors such as work issues, family circumstances and benefits/economics)

Assessment should be person centered and holistic, and should include:

• Mental state examination
• Physical health examination
• Safety/Risk
• Developmental milestones
• Social circumstances/ history
• Past medical history Past psychiatric and physical history
• Current psychiatric and physical history
• Past and current treatments
• Collateral information 

VS model is a psychological theory that attempts to explain a disorder, or its trajectory, as the result of an interaction between predispositions vulnerability, the diathesis, and stress caused by life experiences. 

It is a new perspective on recognizing and building resilience for people with a diagnosis of mental illness

Stress is a part of living, essential for life, it's when stress becomes distressed that it is harmful 

Strengthen resilience = reducing vulnerability 

Neuroplasticity- the brain continually reorganizes itself by forming new neural connections throughout life

Excitatory - excitatory effects on the neuron - increase the likelihood that the neuron will fire an action potential -  dopamine, adrenaline, noradrenaline,  acetylcholine, histamine, Glutamate

Inhibitory - Inhibitory effects on neurons - decrease the likelihood that the neuron will fire an action potential - GABA, Serotonin, Dopamine 

Modulatory (neuromodulators) - are capable of affecting a larger number of neurons at the same time - dopamine, serotonin, acetylcholine, histamine 

Depression is a common mental disorder. It is characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities. It can also disturb sleep and appetite. Tiredness and poor concentration are common.

• family history and genetics.
• chronic stress.
• history of trauma.
• gender.
• poor nutrition.
• unresolved grief or loss.
• personality traits.
• medication and substance use
• nutrition 
• environmental issues (finances, housing, 
• social (support network, gender, social status, race)

Mood - extreme sadness, misery, dejection 

Anhedonia - loss of pleasure and enjoyment in life 

Apathy - loss of interest, enthusiasm, motivation

• Depressed mood*
• Loss of interest*
• Reduction in energy*
• Loss of confidence or self-esteem
• Loss of energy/libido
• Unreasonable feelings of self-reproach or inappropriate guilt
• Recurrent thoughts of death or suicide
• Diminished ability to think/ concentrate or indecisiveness
• Change in psychomotor activity with agitation or retardation
• Sleep disturbance
• Change in appetite with weight change
• Poor concentration
• * Core features  

MILD - 2 core features + 2 additional 

MODERATE - 2 core features + 4 additional 

SEVERE - 3 core features + 4 additional 

Symptoms must be persistent for at least 2 weeks 

Two general questions have proven to be sensitive in screening for depression:

1. During the last month, have you often been bothered by feeling down, depressed or hopeless?

2. During the last month, have you often been bothered with having little interest or pleasure in doing things? 

Mild depression - monitoring progress, exercise, self-help

Moderate depression - CBT + Counselling 

Severe depression - antidepressants (SSRI - selective serotonin reuptake inhibitors - citalopram, fluoxetine, sertraline; SNRIs - serotonin/noradrenaline reuptake inhibitors - venlafaxine; Atypical - mirtazapine, TCAs - tricyclic antidepressants - amitriptyline, doxepin, MAOIs - monoamine oxidase inhibitors - phenelzine)  combination therapy, mental health teams 

Panic disorder is an anxiety disorder where you regularly have sudden attacks of panic or fear. 

According to DSM-5, a panic attack is characterized by four or more of the following symptoms: Palpitations, pounding heart, or accelerated heart rate, Sweating, Trembling or shaking, Sensations of shortness of breath smothering, A feeling of choking, chest pain or discomfort, nausea or abdominal distress, Feeling dizzy, unsteady, lightheaded, or faint, Feelings of unreality (derealization) or being detached from oneself (depersonalization), Fear of losing control or going crazy, Fear of dying, Numbness or tingling sensations (paresthesias), Chills or hot flushes

Safety Seeking Behaviours - a behavior which is performed to prevent or minimise a feated catastrophe 

Attention Deployment  - attention away from the threat 

Spontaneous Imaginary - spontaneously occurring mental images, enhancing perceptions of threat 

Emotional reasoning - a cognitive process that concludes that the emotional reaction proves something is true, despite contrary empirical evidence 

Memory processes - a tendency for anxious individuals to selectively retrieve information that appears to confirm their worst fears 

Modeling - the therapist demonstrates how to approach the phobic object while being observed by the patient 

Role-play - allows direct observation of the problem behaviour

Rehearsal - of new possibilities can be carried out invitro, building up confidence steps by step 

The basic idea is to gradually is to be exposed to the feared situation in a way that allows controlling fear at each step. 

• Preparation - the procedure should be clearly explained, concerns should be discussed in advance, advantages + disadvantages should be revealed, 
• Creation of an exposure hierarchy - list of objects or situations which are feared, SUD rating + ranked from the least to the most anxiety provoking (an exposure hierarchy) 
• Initial exposure - start with an item that evokes moderate anxiety (SUD 4 or more), initial exposure should take place during a therapy session, and the patient should be asked for a SUD rating periodically during the exposure 
• Repeated exposure - exposure should be graduated, repeated, and prolonged 

4 GOLDEN RULES: Long enough, often enough, use relevant situations, ultimately alone 

Habituation is a decrease in response to a stimulus after repeated presentations

Organism learns to stop responding to a stimulus which is no longer biologically relevant 

BA - mid 1990s - Jacobson 

BA is an approach that focuses on using behaviours to "activate" pleasant emotions 

Behavioural Activation does not focus on an internal cause of depression, it focuses on the whole event and variables that may influence the occurrence of unhelpful events 

A more proactive way of breaking the vicious cycle of depression is to increase our level of activity even if we don’t feel like it to begin with

Monitoring daily activities to understand the relationships between the activity and our mood - activity monitoring sheet 

Once the activity is monitored for a week, an activity monitoring record can be used to look for patterns between the activity and the mood

Routine activities: chores, meals, sleep

Pleasurable: socializing, hobbies 

Necessary: paying bills, finances

Note activities that have a positive and negative impact on the mood 

PD occurs when personality traits become rigid, maladaptive, and fixed.PD affects cognition, behaviour, and style of interacting with others. 

Common features:

• disturbances in self-image 
• inappropriate range of emotions 
• poor impulse control 
• long standing problems in personal relationships - dependency or withdrawal 
• reduced occupational functioning 

Cluster B share dramatic, emotional, or erratic behaviors 

Cluster B sufferers are susceptible to substance abuse, impulse control, and suicidal behaviour. 

Emotionally unstable personality disorder causes significantly impaired functioning, including a feeling of emptiness, lack of identity, unstable mood and relationships, intense fear of abandonment, and dangerous impulsive behaviour, including severe episodes of self-harm. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair

Causes: 

abuse (sexual, psychological, emotional); being bullied, neglect

genetics 

Adaptive Schemas: 

• Secure attachments to others 
• Able to express valid needs + emotions 
• be spontaneous / playful 

Maladaptive schemas: 

• Abandonment, instability
• mistrust/abuse
• emotional deprivation
• approval seeking 

Schema: a pattern of repeated actions

Mentalisation - combines group + individual therapy. It aims to help to better understand self + others, strengthens patients' capacity to understand their own and others' mental state, it addresses difficulties with affect, impulse regulation, and interpersonal functioning. (MBT - mentalisation-based treatment - expensive, partially hospital-based, over a period of 36 months). 

DBT (Dialectal Cognitive Therapy) - a combination of cognitive + behavioural therapies, with techniques from ZEN Buddhism 

CBT - a way to change unhelpful patterns of thinking 

Schema Focused Therapy - a cognitive therapy that explores and changes the collection of deep unhelpful beliefs 

Medications - Antidepressants - help with the mood and emotional difficulties that people with cluster B have 

Lithium - mood stabilizer