B7 psych/OMS III

psychotherapy

Scientifically validated, non-somatic treatment that attempts to change patterns of psychological functioning through insight, understanding, or changes in behavioral functioning

talk therapy

counseling

therapy (distinct, however, from schools of counseling)

psychotherapy is also referred to as (3)

eating disorders, personality disorders

psychotherapy is first line treatment for many disorders, such as:

psychotherapy + psychotropic medication

psych therapy regimen that tends to produce the best outcomes

a range of trained professionals including:

-psychologists (PhD/PsyD)

-social workers (LCSW)

-counselors (LPC)

-psychiatrists (MD/DO), etc.

who all can practice psychotherapy?

psychoanalytic-related pscyhotherapies

what type of psychotherapy?

-Focus on unconscious processes as they are manifested in present behavior (making the unconscious conscious)

-Aim to increase patient's self-awareness and understanding of the influence of the past on present behavior

transference, countertransference, and Ego defense mechanisms

commonly discussed aspects of psychoanalytic therapy:

Id

unconscious psychic energy

ego

the executive mediator

superego

internalized ideals outside awareness but accessible

transference

projection of unconscious feelings about important figures in the patient’s life onto the therapist

countertransference

Projection of unconscious feelings about important figures in the therapist’s life onto the patient

defense mechanisims

unconscious processes used by the ego to protect oneself and relieve anxiety

controlling

which defense mechanism?

-Attempting to manage or regulate events or objects in the environment to minimize anxiety and to resolve inner conflicts.

displacement

which defense mechanism?

-Redirecting of thoughts feelings & impulses directed at one person or object, but taken out upon another person or object

intellecutalization

which defense mechanism?

-Works to reduce anxiety by thinking about events in a cold and clinical way.

rationalization

which defense mechanism?

-Involves explaining an unacceptable behavior or feeling in a rational or logical manner, avoiding the true reasons for the behavior.

reaction formation

which defense mechanism?

-Converting of unwanted or dangerous thoughts, feelings or impulses into their opposites.

repression

which defense mechanism?

-Unconscious blocking of unacceptable thoughts, feelings and impulses.

acting out

which defense mechanism?

-Performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing.

denial

which defense mechanism?

-Blocking out or disowning painful thoughts or feelings.

regression

which defense mechanisim?

-Reversion to an earlier stage of development in the face of unacceptable thoughts or impulses.

projection

which defense mechanism?

-Involves taking our own unacceptable qualities or feelings and ascribing them to other people.

splitting

which defense mechanism?

-Viewing of self or others as either all-good or all-bad

undoing

which defense mechanism?

-Attempt to take back an unconscious behavior or thought that is unacceptable or hurtful.

classic psychoanalysis

which type of psychotherapy?

-based on original principles of Freud (use of free association); involves intense therapeutic relationship with frequent visits (2-3 years)

psychodynamic therapy

which type of psychoanalysis?

-(2+ years) aimed at changing an aspect of one's identity or personality to integrate missed key developmental milestones; less rigid than classic psychoanalysis; here and now

brief psychodynamic therapy

which type of psychotherapy?

-(generally 25 sessions max): typically used for one major focus, i.e., substance abuse

insight-oriented psychotherapy

which type of psychoanalysis psychotherapy?

-focus is on current life conflicts and defenses; goal is to achieve intellectual understanding of ways they can change behavior (vs reliving through transference)

behavior therapy

Developed from theories of classical conditioning (Pavlov) and operant conditioning (Skinner)

-Based on assumption that behavior is influenced by learning, therefore environmental conditions are important factors

-Focus is on correcting pathological behavior NOT emotions

conditioning, such as positive reinforcement, to alter patterns of behavior

approaches used in behavior therapy

disorders associated with unhealthy behaviors

-substance abuse, eating disorders, anxiety disorders, phobias, and OCD

indications for behavior therapy

• Aversion Therapy

• Systematic Desensitization

• Flooding

• Relaxation Training

• Biofeedback: treats migraine, chronic pain

types of behavior therapy

cognitive therapy

Originally developed by Aaron Beck in mid 1960s

-Most commonly used to treat depression and anxiety

-Goal is to recognize and correct faulty assumptions/thoughts that lead to negative feelings

depression and anxiety

cognitive therapy is most commonly used to treat

negative views of self, situation, future

what are the 3 major cognitive patterns in depressed pts (cognitive triad)

cognitive behavioral therapy

Commonly used derivative of cognitive therapy

-Most widespread use is for depression, also used for anxiety, substance abuse disorders, eating disorders, and others

-Tends to be short-term (6 weeks-6 months) and structured

-Uses both behavioral techniques (homework) and cognitive restructuring to help patients identify and counteract negative automatic thoughts

-Focuses on “cognitive distortions” (dysfunctional patterns of interpretations of life events) and automatic thoughts

arbitrary inference

name the cognitive distortion:

-drawing an erroneous conclusion

selective abstraction

name the cognitive distortion

-taking a detail out of context to degrade an experience

overgeneralization

name the cognitive distortion

-making general conclusions based on a single instance

catastrophizing (magnification and minimization)

name the cognitive distortion

•altering significance of events through negative interpretations

personalization

name the cognitive distortion

-interpreting events as reflecting on the patient when there is no relation

polarized (dichotomous thinking)

name the cognitive distortion

-seeing things as all-or-nothing or in black and white categories; viewing oneself, others and/or the world in only positive or negative extremes

cognitive distortion

a pattern of negative thinking that makes events seem worse than they are

logotherapy

therapy that emphasizes a search for meaning as a construct in mental health, and a prominent factor in our resilience in the face of adversity

•Practitioners take care to avoid dehumanizing the patient, instead integrating their challenges as part of their journey toward meaning and identity

person-centered therapy

therapy that is a Non-prescriptive approach - instead, attempt to create the proper conditions for therapy to occur

1. empathy

2. genuineness

3. unconditional positive regard

what are the 3 pillars of person-centered counseling?

dialectical behavior therapy

Type of CBT developed by Marsha Linehan

•Created to help patients with Borderline Personality Disorder particularly with self-harm behaviors or chronic thoughts of suicide. Also helpful with depression, eating disorders, and substance abuse.

-involves both individual and group work ,as well as coaching

acceptance and change

DBT is based on the dialectic of:

1. Distress Tolerance

2. Emotion Regulation

3. Mindfulness

4. Interpersonal Effectiveness

Comprehensive DBT focuses on four ways to enhance life skills:

supportive psychotherapy

Used to help patients cope with difficult situations, experiences, or periods of adjustment-individualized approach to symptom reduction

-Can be incorporated into most other therapies and is appropriate for full spectrum of psychiatric disorders

-Important aims include affect regulation and behavior goal setting; positive, strength based focus

-Generally, probing underlying motivations and patient's history are avoided

-Therapeutic alliance and conversational style are key components

interpersonal therapy

Developed at Yale University by Klerman & Weissman in the 1970s for treatment of depression

-Based on idea that mental illness may reflect and be expressed in relationship problems

1. Grief

2. Interpersonal disputes

3. Role transitions

4. Interpersonal deficits

the 4 general domains off interpersonal therapy

Often used in combination with biological therapies to treat depression as well as other affective disorders, anxiety disorders, and eating disorders (approx 16 weeks)

indications for interpersonal therapy

group therapy

Provides patients with a social environment and/or peer group to help increase self-awareness and improve interpersonal functioning

•May or may not include a professional facilitator depending on type of group

•Effective for both inpatient & outpatient settings

family and couples therapy

Goals include resolution of conflict in the social relationships; therapist maintains atmosphere of fairness, neutrality, & impartiality

integrative/elective psychotherapy

Individualized approach to therapy in which the therapist is not exclusively committed to one type of psychotherapy

•Based on research that different theoretical approaches to psychotherapy produce similar outcomes

•A blend of evidence-based interventions may be used based on unique client needs.

relationship

Studies have shown that the therapy ____________ is a significant predictor of treatment success across all schools of therapy

personality traits

Enduring, consistent pattern of perceiving, relating to, and thinking about the environment and oneself

•Examples: adaptability, defensiveness, curiosity, selfishness, honesty, loyalty, paranoia, openness to experience, tolerance

"OCEAN"

Openness to experience

Conscientiousness

Extraversion

Agreeableness

Neuroticism

name the 5 broad domains of personality traits under the factor 5 model of personality

•Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

•Pervasive and inflexible

•Onset in adolescence or early adulthood

•Stable over time, representative of long-term functioning (“stably unstable”)

•Leads to distress and/or impairment

•Cannot be explained by another mental illness

•Not caused by substance use or medical condition

personality disorders as defined by DSM-5

•Paranoid

•Schizoid

•Schizotypal

personality disorders within cluster A

•Antisocial

•Borderline

•Histrionic

•Narcissistic

personality disorders within cluster B

•Avoidant

•Dependent

•Obsessive-Compulsive

personality disorders within cluster C

alternative DSM-5 model for personality disorders

NOT included in formal DSM-5 criteria, but may be useful for clinicians & researchers

•Alternative model appears to be more suited for situations where a patient meets criteria for multiple personality disorders, which is not uncommon

•Four items representing personality functioning: Identity, self-direction, Empathy, and Intimacy (requires 2) coupled with between 2 and 7 pathological traits specific to one of the big five PDs

Younger people at greater risk; prevalence decreases with age & if already diagnosed may become less symptomatic with age

-Personality changes that appear later in life suggest presence of another mental disorder, neurocognitive disorder, or a disorder caused by a medical condition or effects of a substance

typical age range of personality disorders

cluster A: the "eccentric" disorders

which cluster of personality disorder?

•Pervasive pattern of abnormal cognition (e.g. suspiciousness),

self-expression (e.g. odd speech), or relating to others (e.g. reclusiveness)

no

are the cluster A disorders marked by psychosis?

schizoid

Voluntary social withdrawal, limited emotional expression, content with social isolation

schizotypal

Peculiar behavior, odd speech, "magical" thinking, and unusual perceptual experiences, few close relationships

cluster B: the "dramatic" disorders

which cluster of personality disorder?

•Pervasive pattern of violating rights of others or social norms, excessive emotionality, impulsivity, grandiosity, or "acting out"

antisocial personality disorder

which cluster B disorder?

Disregard for & violation of rights of others, criminality, pathological lying/deceitfulness, impulsivity; at risk for alcohol abuse

Symptoms must be present since age 15

- Individual must be at least 18 years to diagnose

what are the age criteria for antisocial personality disorder?

borderline personality disorder

which cluster B disorder?

-Unstable mood and relationships, impulsivity, self-injury and suicidal behavior, identity disturbance, emptiness, fear abandonment

-high rates of self-injury

histrionic personality disorder

which cluster B disorder?

Excessive emotionality and attention-seeking behavior, overly concerned with appearance, sexually provocative, easily influenced by others

Narcisstic Personality Disorder

which cluster B disorder?

Grandiosity, sense of entitlement, lack of empathy, hypersensitivity to evaluation by others, egotistical, interpersonally exploitative

-May appear outwardly charming

-Common belief he/she deserves the "best" or special treatment

cluster C: the "anxious" disorders

which cluster of personality disorder?

•Pervasive pattern of abnormal fears regarding social relationships, separation, and need for control

avoidant personality disorder

which cluster C disorder?

socially inhibited, introverted, self-conscious, anxious, sense of inadequacy, mistrustful, desire social relationships, socially awkward

dependent personalty disorder

which cluster C disorder?

Relies excessively on others for emotional support, submissive and clingy, fear of separation, indecisive

obsessive-compulsive personality disorder

which cluster C disorder?

.Preoccupation with orderliness, perfectionism, and mental and interpersonal control; lacks flexibility, openness, and efficiency; experienced as a feature of who they are

•More common in higher SES groups and those w/higher levels of education

•Little insight into maladaptive traits, therefore presence of personality disorder is rarely reason for seeking help

•Tend to present with mood symptoms, domestic troubles, difficulties at work--consequences of pervasive personality issues

most common initial presentation of personality disorder

comorbid mental disorders

Depression most common; also common are other mood, anxiety, substance use, and eating disorders

nearly all individuals with personality disorders also have

•Pharmacologic treatment for personality disorders is not well studied; currently NO medications approved by FDA for any personality disorder

•Medication may help with some symptoms associated with personality disorders (e.g. depressed mood, anger, impulsivity, hopelessness)

are personality disorders treated with medication?

Dialectical Behavior Therapy (DBT) & Cognitive Behavioral Therapy (CBT)

borderline personality disorder is often treated with

hallucination

FALSE sensory perception experienced without real external stimulus

illusion

Misperception of real external stimulus

delusion

Strongly held fixed beliefs or opinions not based on evidence

sensory

hallucination is a _____ disturbance

perceptual

illusion is a __________ disturbance

belief

delusion is a _________ disturbance

hallucination

most common form of perceptual abnormalities

auditory and visual

what are the more common types of hallucination?

-mental health disorders

-delirium general altered sensorium

-charles bonnet syndrome

-substance use

hallucinations most often result from

•Parkinson’s & Alzheimer’s disease, and other forms dementia (especially Lewy body dementia)

dementias most associated with hallucinations

charles bonnet syndrome

Visual hallucinations in those with partial or severe blindness & are often aware that they are having a hallucination

Cannabis, Methamphetamine, and EtOH

-hallucinogens: LSD, DMT, MDMA, psilocybin

most common substances causing hallucinnation

delusional parasitosis

pt believes (incorrigibly) that they are infested with some parasite

-often have received rx or antiparasitic agents like ivermectin from other doctors or providers

-esp assoc with METH

Hypnagognic Hallucinations

hallucinations that occur as one is going to sleep

Hypnopompic hallucinations

Hallucinations that occur as one is waking up

-medications: antipsychotics

-tx underlying medical conditions

-REHAB! ask if they will go

-psychotherapy such as cognitive behavioral therapy

principles of treatment for hallucinations