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slartibartfast

COMPLETE SUPEREGO PMPs

21 posts in this topic

Holy crap! That's a lot of PMPs. :o

The effort is much appreciated though, as always!

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53. Lady in 30s or so referred to you with history of resilient depression and recurrent self harming. Has been few years in psychotherapy with no improvement. How will you assess and manage? (What may be responsible for failure to improve? What factors may make her not benefit specifically from psychotherapy? Which psychotherapeutic interventions are available in this case? Briefly describe what each entails? Which has best evidence in this case-recurrent DSH? What is the natural history of this case if left untreated?)

any help with this? why has psychotherapy failed and what are the options for mx

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53. Lady in 30s or so referred to you with history of resilient depression and recurrent self harming. Has been few years in psychotherapy with no improvement. How will you assess and manage? (What may be responsible for failure to improve? What factors may make her not benefit specifically from psychotherapy? Which psychotherapeutic interventions are available in this case? Briefly describe what each entails? Which has best evidence in this case-recurrent DSH? What is the natural history of this case if left untreated?)

any help with this? why has psychotherapy failed and what are the options for mx

Let's try.

This is a psychotherapy question

Key issues:

1. Assessment of lady again for ddx

2. Assessment of risk, need and fitness for continuing psychotherapy

3. Management according to point 2

1.

- Ask referrer (who?) - why refer? / why not improve? (psychotherapy not useful, counter-transferance). Previous med / psy hx / self-harm, given treatment (dose, type, suboptimal duration or type)? Wrong diagnosis? compliance to follow-up, treatment, therapy sessions? default FU? why? Poor therapeutic relationship?

- Ddx in mind: depression +/- dysthymia, borderline PD, +/- co-morbid SA/anxiety

(also rule out psychosis, organic that makes treatment resistance likely)

- See patient with clear explanation of purpose of assessment (may not take over the case)

- Empathic and take note of borderline PD's unstable ego affecting the conversation

- Note transference / counter-transference which aids assessment

- Re-take HPI/past hx/background/hx of violence or suicide/premorbid personality/drug use

- Pay particular attention to childhood abuse / parenting / bullying / relationship unstability / personality of prone to boredom, frusturation. Impulsiveness

- MSE: mood / psychosis / insight

- P/E: previous self-harm markings, neurological signs, thyroid, vitals

2.

Psychodynamic therapy is not suitable for ones with:

- low ego-strength and prone to emotional breakdown when stress comes (borderline PD)

- not enough psychological mindedness - did not understand what psychological difficulties he has and couldn't explain the underlying reasons for his / her difficulties

- not motivated to have the therapy

- for borderline PD, the explorative way to patient's past history may traumatize patient, leading to breakdown again

- for severe depressive disorder, life-saving and biological method is the first importance

- safety issue if the risk of self-harm or harming others is high

- actually psychodynamic therapy has not got enough evidence-based for both depression and borderline PD

3.

Suggestions to patient

- If risk is high / severely depressed / life-saving: in-hospital management first

- For out-patient managment consider

Treat according to underlying diagnosis

If depression exists (Mild to moderate)

cognitive behavioural therapy (cognitive distortion: Beck's triad / autonomic thoughts / types of cognitive distortion / behavioural - advise not to inactivity, activity rescheduling); ?medication input (revise regime and dose, SSRI)

If borderline PD exists:

DBT (RCT by inventor, CP + social skills + telephone consult) - evidence for female with mild severity of self harm only

Treat co-morbid disorders as well (SA - motivational interview, detox, abstinence) / mood - SSRI

Other psychotherapies:

- interpersonal therapy (a type of CBT, focus on relationships)

- cognitive analytical therapy (semi-structured psychodynamic therapy)

- Psychodynamic if patient strongly requests and risk is not high

Liase your managment with referrer

Consider other disciplinary input (family, CPN, CMHT, OT, social worker, self-help group)

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joeylung this is beautiful :)

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slartibartfast Great work not many people are as altrustic

we need more like you :)

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Hi,

it's a great work..but am just wondering is there any printable version(I knoiw am being verygreedy for asking more)

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Just copy paste the whole thing into word!

Comes out with 95 pages!!

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Thanks Aimee..My god, I am having a sinking sinking feeling thinking about 95 pages..hopefully there might be some repeats..

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Oh my God! I hope I HAVE failed the written!

I hadn't dared think about the clinical, but that is terrifying.

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Oh my God! I hope I HAVE failed the written!

I hadn't dared think about the clinical, but that is terrifying.

:lol: :lol: :lol: :lol:

dont worry too much Ros.. u will be fine..

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Actually, the stuff that is making me really panic is the legal bits and pieces. So if I learn the Capacity Act, the Mental Health (properly!) and parental responsibility (again), I'll probably feel a whole lot better. And if I don't get the written this time, it should come in handy for the OSCEs in Spring.

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I agree... it will be wise to start now... PMPs are there as OSCE stations in Part 3 anyway... so that wouldnt go to waste...

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boy thats a commendable job.....u hav a lot f patience to giv so much info........amazing.....makes our life easy to a great extent (that is f v pass theory paper!!!).

can u also giv some info on what books/material to read. is attending any course helpful?

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I think there are too many PMPs thats why my comp.. wont open it...

my comp.. likes small files :lol: Is there any other way round to find the PMPs that u have posted. Thanks

Pandit...

Collected all the pmp's ever posted.. off sick at home with a chest infection and nothing else to do..

anyways here are the complete collection of all the pmp's..

be warned its a lotta pmp's and theres also a lotta repeats..

here it is..

http://www.geocities.com/zingdoozer/pmps.txt

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