Questions for this month’s clinical challenge are based on articles in this issue. The style and
scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship
exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional
Development Program and has been allocated 4 Category 2 points per issue. Answers to this
clinical challenge are available immediately following successful completion online at www.
gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the
2011–13 triennium, therefore the previous months answers are not published.
Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www. gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.
Depression and anxiety
You are keen to have a structured approach to consultations with patients who have depression and anxiety.
You are aware cognitive behavioural therapy (CBT) is a strategy used in depression, but are wondering about the evidence for efficacy. Your research on the subject reveals:
- CBT has been shown to be an effective treatment for mild to moderate depression
- CBT has no efficacy in anxiety disorders
- CBT is appropriate in adults but not children
- for CBT to be effective, it needs to be a time intensive therapy
- the most benefit from CBT is seen in patients with chronic pain.
All of the following can be considered forms of cognitive behavioural therapy EXCEPT:
- guided thought identification and challenge
- narrative therapy
- relaxation strategies
- sleep hygiene
- structured problem solving.
You are considering which of your patients might benefit most from CBT. For which of the following patients is CBT most likely to be appropriate:
- 6-year-old boy with primary nocturnal enuresis and attention difficulties
- 22-year-old male university student who is struggling with motivation and low mood but denies suicidal ideation
- 38-year-old female with long term marijuana and alcohol dependence
- 46-year-old female with Down syndrome and arachnophobia
- 87-year-old female with depression and worsening diabetic control, such that you suspect she is forgetting her medications.
Which of the following is a factor associated with success that may be LEAST amenable to assessment early in the CBT process:
- agreement on formulation and plan
- optimism and willingness to try therapy
- patient ability to recognise thoughts and their links
- support from family and friends for changes.
June, 54 years of age, has suffered with debilitating chronic back pain for 8 years. Despite multiple attempts at physiotherapy, chronic pain clinic referrals and various analgesic medications, her function has not improved. You have begun to dread her visits and decide a new approach is needed.
Your recall acceptance and commitment therapy (ACT) has efficacy in chronic pain. ACT asks that patients engage in all of the following processes EXCEPT:
- attend the present moment with self awareness
- eliminate automatic thoughts, sensations and urges
- observe thoughts without believing them
- clearly articulate values
- engage in committed action.
You introduce ACT to June. You discover she strongly believes that any activity will do her back further harm so she spends a lot of time sitting or lying at home. Initially, she can acknowledge that her pain beliefs may not be correct but then again focuses on her impairment and becomes distressed. She will not consider any attempt to increase her activity. When scoring June in the ACT framework, the most appropriate assessment based on the history would include:
- acceptance of experiences (1), values clarity (0)
- mindfulness (3), committed action (1)
- defusion from thought (0), acceptance of experiences (–3)
- self as context (2), defusion from thought (2)
- committed action (2), mindfulness (1).
Activities you could use within the ACT framework to help June to treat her thoughts as unimportant include all EXCEPT:
- creating a book with chapters addressing identified barriers to change
- graduated activity scheduling
- have the patient ‘watch’ their thoughts and indicate content as past, present or future
- saying a painful self belief out loud and learning to treat the phrase as merely a sound stimulus
- writing thoughts on a card to allow ‘contact’ with the thought.
You are pleased with June’s response and determine to try to work in an ACT consistent manner with other patients. The following may be useful EXCEPT:
- asking, ‘What have you tried to cope with this problem?’
- asking ‘What’s the next step you could take to live more like you want in the area of …?’
- modelling acceptance of uncomfortable life experiences
- reflecting the patient’s psychological experience in a defused manner
- reinforcing societal messages that particular emotions need to be eliminated before life enhancing actions can be taken.
Roberta, 55 years of age, is a regular patient to your practice. She reports fatigue, headaches and tearfulness. You establish her 18-year-old daughter Isabelle has recently left home and Roberta is concerned for her safety. The situation has caused conflict between Roberta and her husband Joseph as he is refusing to speak to Isabelle. Roberta is feeling overwhelmed by the situation.
If you were to use problem solving therapy (PST) to help Roberta work through her situation, a method you may employ would be:
- ask Roberta to bring her family in next week for a group discussion
- advise Roberta to support her daughter, but allow her to make her own mistakes
- help Roberta to clearly identify the problems
- refer Roberta to a psychologist
- take Roberta through a guided relaxation.
Roberta determines one problem to be disagreement with Joseph about how to handle Isabelle’s behaviour. The next step in the PST process would involve:
- asking Roberta to brainstorm solutions
- agree with Roberta that there really is no solution to this problem
- assisting Roberta to develop some clear goals that she would like to achieve
- suggesting ways Roberta could communicate more effectively with Joseph
- telling Roberta she should maintain contact with her daughter regardless of Joseph’s wishes.
At your next consultation, Roberta reports that she and Joseph are communicating better after she implemented her chosen strategies. Her headaches have also settled. Theories regarding why PST is an effective treatment in depression include:
- the patient identifies patterns of negative thinking
- the patient achieves problem resolution
- the patient feels a sense of empowerment from developing problem solving skills
- both B and C
- both A and B.
You tell a colleague about your success with Roberta. What information can you provide on the efficacy of PST treatment in major depression:
- the quality of available evidence is low
- PST is no more effective than placebo
- PST is not as effective as CBT
- PST is most effective when combined with antidepressant medication
- PST has been shown to be equally as effective as antidepressants.
Edgar, 55 years of age, is a new patient to your practice. You have performed a cardiovascular risk assessment. Edgar has returned to discuss the results. His BMI is 31, BP 170/95 mmHg, he smokes, has impaired glucose tolerance and an LDL cholesterol of 4.5 mmol/L. You decide to employ some motivational interviewing strategies to assist Edgar in reducing his risk.
Edgar has been thinking that he should quit smoking at some point. The most appropriate approach for Edgar at this time would be:
- raise doubt in his mind and provide harm reduction strategies
- help him develop clear goals to take steps toward quitting
- increase confidence in his ability to change
- list all the reasons he should stop smoking
- help Edgar use strategies to prevent relapse.
All of the following are counselling techniques that constitute the basic skills of motivational interviewing EXCEPT:
- open-ended questions
Edgar identifies his poor diet and excess weight makes him feel bad about himself. To help move him toward behaviour change you could:
- agree with his self assessment and tell him he needs to try harder
- ask Edgar what would be different in his life if he lost weight
- refer him to a dietician and exercise physiologist
- ask him to rate the importance of losing weight on a scale of 1 to 10
- B and D.
Edgar confesses he drinks five ‘stubbies’ of beer most nights and he is not prepared to decrease this. You immediately respond by telling him all the negative effects this will have on his health and why he has to cut down. This is an example of:
- empowering your patient
- patient education
- rolling with resistance
- the ‘righting reflex’
- understanding your patient’s motivations.