Introduction to Psychotherapy

Psychodynamic Therapy

• The first therapy developed by Freund and later honed by Jung, Adler, and Klein

• Freund conceptualized he could help change patterns of behavior by helping clients understand the unconscious reasons for their origin

  • Clinician is neutral and non-reactive

• Emphasis on how past and present life events and relationships affect current feelings, relationships, and choices

• Emphasis on unconsciousness

  • Id: impulsivity/pleasure seeking

  • Ego: realism, decision making, mediates between id and superego

  • Superego: moralizing, judgement,

• Goal

  • Help clients find self awareness and understand the influence of the past on one’s behavior

  • Helps to recover repressed memories

  • Popular treatment for people with depression and trauma

• Pillars

  • Free association

    • Given stimulus and client speaks/draws freely

  • Processing transference (projection of unconscious feelings onto others) projection (putting one’s own biases onto another person/group), resistance (resisting repressed unconscious feelings or drives to be brought into conscious analysis)

  • Dream analysis

  • Early childhood influences and family of origin

Cognitive Behavioral Therapy

• Theorized by Dr. Albert Ellis rational emotional therapy

• Founded on premise that thoughts control behaviors

  • Found that people with depression have a very negative thought pattern

• Very structured and time limited

• Recognize cognitive distortions or thinking traps

• Clinician is neutral and non-reactive

• Lots of worksheets

• Pillars

  • Core belief: a person grows up in a home with a very negative attitude (always told that they are stupid) and the child grows up believing the negative comments that were made to them

  • Cognitive triad

  • Cognitive distortions and restructuring (resetting your mind, challenging distortions, modifying your negative belief system through very concrete modeled coping skill bhevaiors)

    • Catastrophization

    • Should statements

Dialectical Behavioral Therapy

• Form of CBT that aims to give people skills to regulate emotions, improve relationships, handle stress, and live mindfully

• First used to treat people with borderline personality disorder

• Primary principle

  • Teach that experiences are real but radical acceptance, coping skills, and mindfulness can help handle negative feelings, interpersonal conflict, and impulsive tendencies

• Hallmark of people who benefit from DBT is people with big feelings, or people who use maladaptive coping like substance use, etc…

• Clients can’t fail

• Pillars

  • Mindfulness: being aware of the moment

  • Distress tolerance

  • Emotional regulation: getting through a negative feeling in a healthy way

  • Interpersonal effectiveness: getting needs met in a relationship appropriately

Motivational Interviewing

• Developed by Dr. William Miller and Dr. Stephen Rollnick

• Developed to manage ambivalence in clients (substance use and smoking cessation): utilized to encourage clients to connect to the part of themselves that wants to change by giving them the opportunity to express themselves in a non-judgemental setting

• Teaches the clinical to use open ended questions and validation

• Important factors

  • Eliciting change talk from the client

  • Pillars are achieving a therapeutic alliance

• Examples of open ended questions

  • What are the positives about your drinking? What are the negatives?

  • What have other people told you about your substance use?

Interpersonal Therapy

• Developed by Dr. Gerald Klerman and Dr. Myrna Weissman to treat depression

• Short term 12-16 weeks

• Focuses on relieving symptoms by improving interpersonal functioning

• Addresses current problems and relationships versus childhood or developmental issues

• Therapist is active and not neutral

• Goal: improve quality of client’s interpersonal relationships and social functioning to help reduce overall distress

• Explores current relationships

• Addresses maladaptive thoughts and behaviors only as they apply to interpersonal relationships

• Aims to change relationship patterns and difficulties rather then target depressive symptoms

• Overall less direction than CBT

• Process

  • Evaluation

  • Identification of problem

  • Exploration of patterns

  • Development of coping skills

  • Termination and follow up

Supportive Psychotherapy

• Developed after psychoanalysis

• Typically used when other forms of therapy are not suitable

• Integrative approach, can use a variety of schools of thought

• Includes empathy, reassurance, psychoeducation, and support (combination of all other methods)

• Therapist is active and not neutral

Community Resources: Enhanced care clinics

• Most of them have walk appointments for initial intake

• Can go with any insurance or no insurance

• Cons

  • Long wait time to meet a therapist

  • Must show commitment before med management

Community Resources: PsychologyToday.com

• Good option for patients with insurance

• Online phonebook for psychiatric professionals

• Can be filtered based on city, specialty, insurance

Community Resources: Mobile crisis (211)

• Can call in a crisis

• Can send someone over for a check if needed

Community Resources: CCAR

• Connecticut Community for Addiction Recovery

• Can aid in referrals and finding treatment for alcohol or substance abuse

Community Resources: ACT (assertive community treatment)

• Multidisciplinary team

• Allows chronically ill people to live in the community

• Come to the client

Community Resources: Suicidal Hotline (988)

• 24/7 can call for suicide crisis

• Can also test

Principles of Treatment

• Patient-provider relationship

  • Shared decision making

• Maintain attention to the biopsychosocial picture/causation

  • Is this is a psychological or more biological problem

  • Most purely psychological issues not responsive to medications

• Most are going to be more than one intervention (combination of therapy and/or medications)

• Ultimate goal: control, provide level of function, remission, strategies to mitigate

Psychopharmacotherapy: the drugs

• Most psychotropic medications are lipophilic

  • Rapid absorption

  • Cross BBB

  • Avoids first pass metabolism in the liver

• Act on neurotransmitters or their binding site

  • Quick action but for some longer onset of therapeutic benefits

  • Side effects

  • Toxicity

• Side effects

  • Many require ongoing monitoring

  • Many have specific side effect profiled based on the neurotransmitter affected

  • Can’t abruptly use → discontinuation syndrome

• Lithium and GABA not metabolized by the liver: rest have to go through the liver to have effects on the body (need functioning liver to have an effect)

Psychopharmacotherapy Considerations

• Risk to benefit ratio

• Many side effects

  • Drug-drug interactions

  • Coexisting conditions (chronic health conditions)

• Dealing with side effects

  • Open discussion with patients prior to starting

  • Patient priorities, which may change

  • Medical conditions that can be caused by meds

  • Need for monitoring and other evaluations (EKGs, medication and other chemistries)

• Use of drugs or alcohol while in medications

• Life ambitions/events

  • Pregnancy: effects on fetal development, mother’s ability to get pregnant, risk for preterm labor

Serotonin

• Too little: anxiety, depression, constipation

• Too much:

  • N/V (have receptors in the gut)

  • Diarrhea

  • Decrease sex drive

  • Serotonin syndrome (life threatening)

• GI

Dopamine

• Action

  • Mesolimbic tract (ventral trigeminal area): addiction/reward pathway

  • Mesocorticol tract (prefrontal cortex): mania, psychosis, cognitive, motivation

  • Nigostratial path: Parkinson’s

  • Anything with muscular: think dopamine

• Too little:

  • Parkinsonism (symptom that makes it look like PD)

  • Disinhibition of prolactin secretion

  • Decreased sex drive

• Too much

  • Psychosis

  • Tics

  • Skin picking

  • Aggression

  • Anxiety

  • Hyperkinesia

NE

• Action

  • Neurotransmitter of the sympathetic fight or flight response

  • Increase sympathetic and decrease parasympathetic

• Too much:

  • Weakfulness

  • Anxiety

  • Hyperfocus

  • Defense mechanisms

  • Increased cognition

• Too little:

  • Orthostasis

  • Sedation

  • Bradycardia

  • Depression

  • Lack of motivation

  • Increased parasympathetic

GABA

• Actions

  • Inhibitory neurotransmitter part of the down regulation pathway, reducing neuronal activity

• Too much:

  • Increased sedation/lethargy

  • Weakfulness

  • Confusion

  • Blurry vision

  • Ataxia

• Too little (think about what too much alcohol would do):

  • Seizure

  • Death

  • Anxiety

  • Increased or hyper-neuronal transmissions

  • Formication

  • Psychosis

  • HAs

  • Nausea

  • Tremors

  • Hemodynamic instability

Acetylcholine

• Actions

  • Muscle contraction

  • Memory processing

  • Autonomic nervous system

  • Wakefulness

• Too little:

  • Dry mouth

  • Constipation

  • Urinary retention

  • Cognitive impairment

  • Delirium

  • Muscle weakness

• Too much

  • Increased salivation

  • Lacrimation

  • Increased activity

  • Constricted pupils

  • Perspiration

  • Muscle tremors

  • Diarrhea

  • Emesis

  • SLUDGE

Histamine

• Actions

  • Immune cascade

  • Promotes wakefulness and cognition

  • Found in brain and the gut

• Too little

  • Sedation

  • Weight gain

  • Decreased cognition

  • Has downstream effect on acetylcholine: anti-histamine eventually has downstream effect as an anti-cholinergic

  • Similar to anti-cholinergic effects

Antidepressants

• Subclasses

  • SSRIs

  • SNRIs

  • Tricyclic antidepressant: hit dopamine, serotonin, and NE receptors

  • MAO-I

  • Atypicals

    • Bupropion (Wellbutrin)

    • Mirtazapine

    • Trazodone

    • Nefazodone

    • Vortioxetine (Trentelllix)

      • Works on serotonin receptors

      • Pros: has minimal weight gain and less side effects

• Anxiety disorder first line → SSRI

• Most require annual EKG (QT prolongation), as well as renal and/or liver functional tests

• Some have slower onset: 6-8 weeks before major improvements

• Cannot be abruptly stopped nor have others added on to

  • SSRIs and SNRIs worry the most about

  • Atypicals do not have to worry about as much: so broad that the withdrawal syndrome does not feel as bad as something that is very specific like to serotonin

• Most side effects in first 1-2 weeks: can try to mitigate

• Watch for drug-drug interactions

Antipsychotics/Neuroleptics

• First generation: dopamine antagonists

  • Lot of EPS

  • Some hyperprolactinemia

• Second generation: dopamine serotonin antagonists

  • Generally lower risk of movement disorders

  • More metabolic syndrome symptoms coming from dual action between dopamine and serotonin

• Indications

  • Schizophrenia

  • Acute mania

  • Major depressive disorder

  • Delusional disorder

  • Severe agitation/Tourette’s syndrome

  • Borderline personality disorder (treating symptoms)

  • Dementia and delirium (not FDA approved: medications used more for symptoms coming from something else)

  • Psychosis from substance use disorder (treating symptoms)

• Monitoring: therapeutic ranges

  • Monitor Clozaril (Clozapine) serum levels

• EPS Side effects

  • Pseudoparkinsonism

    • Stooped posture

    • Shuffling gait

    • Rigidity

    • Bradykinesia

    • Tremors at rest

  • Acute dystonia

    • Facial grimacing

    • Involuntary upward eye movement

    • Muscle spasms of the tongue, face, neck, and back

    • Laryngeal spasms

    • Life threatening

  • Akathisia

    • Restless

    • Trouble standing still

    • Paces the floor

    • Feet in constant motion

  • Tardive Dyskinesia: classic EPS example

    • Protrusion and rolling of the tongue

    • Sucking and smacking movements of the lips

    • Chewing motion

Mood stabilizers

• Medications to treat bipolar disorder

• Most are anti-seizure medications

• Mechanism of action

  • Inhibit inositol uptake process resulting in its depletion → lithium

  • GABA inhibition → divalporex (Valproic acid)

  • cAMP and GABA inhibition → Carbamazepine

  • Reducing the frequency of excitatory postsynaptic currents, increase glutamate, and enhance GABA release → Lamotrigine

• Monitoring

  • Thyroid

  • Calcium

  • Renal functions

  • LFTs

  • Urine

  • EKG

  • Depakote: metabolized in the liver: need serum level to see therapeutic range but the window is very broad

  • Lithium:

    • Not metabolized and straight up excreted from the kidneys: if there is insufficient renal function, lithium just continues to build up and deposit in the brain, thyroid, bone and kidneys

    • Has a very narrow therapeutic window of serum concentration

• Common side effects

  • Lithium → tremors and increase in thirst

  • Lamotrigine: SJS

Anxiolytics

• Work by inhibiting the sympathetic hormones released by the amygdala and enhancing GABA

• Medications

  • Benzodiazepines

  • Z-drugs

  • Anticonvulsants (Neurontin) and Pregabalin (Lyrica)

  • Propranolol

  • Buspirone (Buspar)

  • Hydroxyzine (Atarax)

• Treat people with panic disorder, generalized anxiety, sleep disorders

• Common side effects

  • Cognitive disorder: very common (mostly with benzodiazepines)

  • Memory impairment

  • Weight gain

  • Excessive drowsiness

  • Increased appetite

  • Abnormal coordination

  • Instability

  • Hyperhidrosis

  • Nasal congestion

  • Decreased libido

• Withdrawal can have seizures and death