NON-PHARMACOLOGICAL MANAGEMENT IN PSYCHAITRY

PRESENTER – Dr.Sriram.R, Final year PG student

CHAIRPERSON – Dr.Sai, Assistant Prof of Psychiatry

ORGANISATION

■PSYCHOTHERAPIES■BRAIN STIMULATION METHODS■NEUROSURGERY AND DEEP BRAIN STIMULATION■REFERENCES

PSYCHOTHERAPIES

■ Interpersonal, relational intervention by trained therapists to aid in life problems■ Goal: increase sense of well-being, reduce discomfort■ Employs range of techniques based on relationship building, dialogue,

communication and behavior change designed to improve the mental of individual patient or group

■ Some therapies focus on changing current behavior patterns ■ Others emphasize understanding past issues■ Some therapies combine changing behaviors with understanding motivation■ Can be short-term with few meetings, or with many sessions over years■ Can be conducted with individual, couple, family or group of unrelated members who

share common issues■ Also known as talk therapy, counseling, psychosocial therapy or, simply, therapy

WHAT IS PSYCHOTHERAPY?

PSYCHOANALYSIS■ Focus on unconscious as it emerges in treatment relationship■ Insight by interpretation of unconscious conflict■ Most rigorous: 3-5 times/week, lasts years, expensive■ Patient (analysand) lies on couch, analyst unseen to eliminate visual cues■ Must be stable, highly motivated, verbal, psychologically minded and be

able to tolerate stress without becoming overly regressed, distraught, impulsive

■ Analyst neutral■ Goal: structural reorganization of personality■ Techniques: interpretation, clarification, working through, dream

interpretation

Sigmund Freud (1856-1939)

Carl Jung (1875-1961)

PSYCHOANALYTIC PSYCHOTHERAPY

■ Psychoanalytic psy chotherapy, in its narrowest sense, is the use of insight-oriented methods only.

■ As generically applied today to an ever-larger clinical spectrum, it incorporates a blend of uncovering and suppressive measures.

■ The strategies of psychoanalytic psychotherapy currently range from expressive (insight-oriented, uncovering, evocative, or interpretive) techniques to supportive (relationship-oriented, suggestive, suppressive, or repressive) techniques.

PSYCHOANALYTIC EXPRESSIVE PSYCHOTHERAPY

■ Also called “insight-oriented”■ Based on modified psychoanalytic formulations■ Couch not used ■ Less focus on transference and dynamics ■ Interpretation, encouragement to elaborate, affirmation and empathy

important■ 1 – 2 sessions/week; open-ended duration■ Limited goals■ It is also one of the treatments recommended for patients with

borderline personality disor ders

PSYCHOANALYTIC SUPPORTIVE PSYCHOTHERAPY

■ Supportive psychotherapy has been the chief form used in the general practice of medicine and rehabilitation

■ Frequently to augment extratherapeutic measures, such as prescriptions of medication to suppress symptoms, rest to remove the patient from excessive stimulation, or hospitalization to provide a structured therapeutic environment, protection, and control of the patient.

■ Indicated in individuals where classic psychoanalysis or insight-oriented psychoanalytic psy chotherapy is typically contraindicated-those who have poor ego strength and whose potential for decompensation is high.

■ Used in individuals going through grief reactions, illness, divorce, job loss, or who were victims of crime, abuse, natural disaster, or acci dent

BRIEF PSYCHODYNAMIC PSYCHOTHERAPY

■ Brief psychodynamic psychotherapy is a time-limited treat ment (10 to 12 sessions) that is based on psychoanalysis and psychodynamic theory.

■ It is used to help persons with depres sion, anxiety, and posttraumatic stress disorder, among others.

■ There are several methods, each having its own treatment tech nique and specific criteria for selecting patients; however, they are more similar than different.

Cognitive therapy■ Cognitive therapy (CT) is a type of psychotherapy developed by

American psychiatrist Aaron T. Beck.

■ CT is one of the therapeutic approaches within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s.

■ Cognitive therapy is based on the cognitive model, which states that thoughts, feelings and behavior are all connected, and that individuals can move toward overcoming difficulties and meeting their goals by identifying and changing unhelpful or inaccurate thinking, problematic behavior, and distressing emotional responses.

Cognitive therapy■ According to Beck's theory of the etiology of depression, depressed

people acquire a negative schema of the world in childhood and adolescence; children and adolescents who experience depression acquire this negative schema earlier.

■ Depressed people acquire such schemas through a loss of a parent, rejection by peers, bullying, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles the original conditions of the learned schema in some way, the negative schemas of the person are activated.

Behavioral therapy

■ Behavior therapy is a broad term referring to psychotherapy, behavior analytical, or a combination of the two therapies.

■ In its broadest sense, the methods focus on either just behaviors or in combination with thoughts and feelings that might be causing them.

■ Those who practice behavior therapy tend to look more at specific, learned behaviors and how the environment has an impact on those behaviors.

Behavioral therapy

■ Although behavior therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviors.

■ Some of the more well known types of treatments are: Relaxation training, systematic desensitization, virtual reality exposure, exposure and response prevention techniques, social skills training, modeling, behavioral rehearsal and homework, and aversion therapy and punishment.

Cognitive/behavioral therapiesGeneral features Examples■ Are manualized■ Are time limited■ The therapist is more

directive sometimes “coach like”

■ Client often is given homework

■ Interpersonal psychotherapy (IPT)

■ Cognitive behavior therapy (CBT)

■ Dialectical behavior therapy (DBT)

■ Behavioral therapy

Interpersonal psychotherapy

■ Time-limited treatment for major depressive disorder■ Developed in 1970’s■ Assumes connection between onset mood disorder and

interpersonal context in which they occur■ Used for variety depressed populations: geriatric, adolescent,

HIV-infected, marital discord■ Can be combined with medication■ Duration: 12 – 16 weeks■ Efficacy demonstrated in randomized trials

What IPT does to the brain

■ Study of 28 pts with MDD found after 6 weeks of IPT vs venlafaxine increased blood flow in the right basal ganglia. In IPT group also saw an increase in posterior cingulate activity.

■ Underscored the importance of limbic and paralimbic recruitment in psychotherapy-medication mediated changes.

Martin Sd. t al. Brain blood flow changes in depressed patients treated with interpersonal psychotherapy or venlafaxine hydrochloride: preliminary findings. 2001 Arc Gen Psych 58:641-648

Copyright restrictions may apply.

Martin, S. D. et al. Arch Gen Psychiatry 2001;58:641-648.

Patients receiving venlafaxine hydrochloride (n = 15), showing activation of right basal ganglia and right posterior temporal cortex, using statistical parametric mapping 96 "Z map" (P = .01), on

1-T normal magnetic resonance imaging template

Copyright restrictions may apply.

Martin, S. D. et al. Arch Gen Psychiatry 2001;58:641-648.

Interpersonal psychotherapy patients (n = 13), showing activation of right basal ganglia and limbic right posterior cingulate cortex, using statistical parametric mapping 96 "Z map" (P = .01),

on 1-T normal magnetic resonance imaging template

Cognitive behavioral therapy

■ Derives from cognitive and behavioral psychological models of human behavior including theories of normal and abnormal development and theories of emotion and psychopathology.

■ Utilizes the cognitive model, operant conditioning and classical conditioning to conceptualize and treat a patient’s problems.

Cognitive behavioral therapy

■ Approach focuses on problems in the here and now■ Treatment is empowering: focus on gaining psychological and practical

skills■ Patient puts what they’ve learned into practice between sessions by

doing “homework”■ Techniques: identify cognitive distortions, test automatic thoughts,

identify maladaptive assumptions■ The therapist takes an active, problem oriented, directive stance.■ Used in wide range mental health problems: depression, anxiety

disorders, bulimia, anger management, adjustment to physical health problems, phobias, chronic pain.

Cognitive behavioral therapy

■ Major Depression (mood disorder)• Cognitive Behavior Therapy (CBT) and

Interpersonal Psychotherapy – 16-20 sessions as effective as imipramine treatment for less severely depressed patients.Elkin I. Archives Gen Psych 46:791-982, 1989.

Cognitive behavioral therapy

■Panic Disorder (anxiety disorder)• CBT – 16 sessions as effective as medication management, better

tolerated and more durable in response.Barlow D. JAMA 283:2529-2536, 2000.

■ Obsessive Compulsive Disorder (anxiety disorder)• CBT (cue exposure and response prevention) as effective as

medication management.Kozak MJ. 2000

Rational emotive behavioral therapy

■ Rational Emotive Behavior Therapy (REBT), was developed by Dr.Albert Ellis in 1955. It has since flourished and spawned a variety of other cognitive-behavior therapies. REBT's effectiveness, short-term nature, and low cost are major reasons for its popularity.

■ REBT's comprehensive approach works best for individuals desiring a scientific, present-focused, and active treatment for coping with life's difficulties, rather than one which is mystical, historical, and largely passive.

■ REBT is based on a few simple principles having profound implications:– You are responsible for your own emotions and actions,– Your harmful emotions and dysfunctional behaviors are the product of your

irrational thinking,– You can learn more realistic views and, with practice, make them a part of you,– You'll experience a deeper acceptance of yourself and greater satisfactions in

life by developinga reality-based perspective.

Dialectical behavioral therapy

■Developed to treat borderline personality disorder■The treatment itself is based largely in behaviorist

theory with cognitive therapy elements ■ Incorporates “mindfulness” (from Zen) as central

component■Therapists specially trained■Patient has individual and group sessions■Focus on self-destructive behaviors especially suicidality■Skills learned: core mindfulness, emotion regulation,

interpersonal effectiveness and distress tolerance

Dialectical behavioral therapy■ Borderline Personality Disorder (personality disorder)

• CBT (Dialectical Behavior Therapy) superior to “treatment as usual” for reducing parasuicide, medical severity of parasuicide, treatment drop-out, number of inpatient hospitalization days.

Linehan M. Archives of Gen Psych 48:1060-64

Group psychotherapy■ Carefully selected participants meet in group guided by trained leader■ Leader directs members’ interactions to bring about changes■ Participants get immediate feedback■ Patients may also have outside individual therapy■ Self-help groups enable members to give up patterns of unwanted

behavior; therapy groups help patients understand why it happens.■ The term can legitimately refer to any form of psychotherapy when

delivered in a group format, including Cognitive behavioural therapy or Interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilised as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

Group psychotherapy

Encompasses theoretical spectrum of therapies: supportive, time-limited, cognitive-behavioral, psychodynamic, interpersonal, family, “client-centered” based on nonjudgmental expression of feelings

Family therapy■ Intervention to alter interactions among family members and improve function■ Interrupt rigid patters that cause distress■ Family systems theory: family units act as though their homeostasis must be

maintained■ Therapy: discover hidden patterns and help family members understand

behaviors■ Many models treatment exist■ Schedule and duration treatment flexible■ Family therapy has several goals: to resolve or reduce patho genic conflict and

anxiety within the matrix of interpersonal relationships; to enhance the perception and fulfillment by family members of one another's emotional needs; to promote appropriate role relationships between the sexes and genera tions; to strengthen the capacity of individual members and the family as a whole to cope with destructive forces inside and out side the surrounding environment; and to influence family iden tity and values so that members are oriented toward health and growth.

Couples’ therapy■ Designed to modify interactions of persons in conflict. Restructures couples’

interaction■ “Marriage counseling” different from therapy. More limited in scope■ Can be with couple or in group■ Indicated when individual therapy fails to resolve relationship difficulty■ Therapy geared toward enabling each partner to see each other realistically■ The goals of therapy for partner relational problems are to alleviate

emotional distress and disability and to promote the levels of well-being of both partners together and of each as an individual.

■ Part of a therapist's task is to persuade each partner in the relationship to take responsibility in understanding the psycho dynamic makeup of personality

Progressive muscle relaxation■ Progressive muscle relaxation is a technique for learning to monitor

and control the state of muscular tension. It was developed by American physician Edmund Jacobson in the early 1920s.

■ Dr Jacobson wrote several books on the subject of Progressive Relaxation. The technique involves learning to monitor tension in each specific muscle group in the body by deliberately inducing tension in each group. This tension is then released, with attention paid to the contrast between tension and relaxation.

■ These learning sessions are not exercises or self-hypnosis.

Progressive muscle relaxation■ A modification of the technique is "Biofeedback" in which one uses external

measuring devices to indicate how successful one is in relaxing and then to use those techniques to relax without the help of external measuring devices.

■ In the training sessions which are started in a darkened room with the learner in a reclined position and eyes closed. The learner is told to relax, just let go. If the learner has any thoughts or physical distractions, relaxation is advised.

■ In each session the teacher reviews tensing one particular muscle group. If the student is slow in learning how to let the tension go for a particular muscle group, that group is focused on in the next session. The learner is told to continue to practice the relaxation technique in their daily lives.

BRAIN STIMULATION METHODS

Electroconvulsive therapy■ Electroconvulsive therapy (ECT), formerly known as electroshock

therapy and often referred to as shock treatment, is a psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses. It is the only currently used form of shock therapy in psychiatry.

■ ECT is often used with informed consent as a last line of intervention for major depressive disorder, mania and catatonia.

■ A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar. Follow-up treatment is still poorly studied, but about half of people who respond relapse within 12 months.

Electroconvulsive therapy■ Aside from effects in the brain, the general physical risks of ECT are

similar to those of brief general anesthesia.

■ Immediately following treatment, the most common adverse effects are confusion and memory loss. ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.

■ A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms. ECT is administered under anesthetic with a muscle relaxant.

Electroconvulsive therapy■ Electroconvulsive therapy can differ in its application in three ways: electrode

placement, frequency of treatments, and the electrical waveform of the stimulus.

■ These three forms of application have significant differences in both adverse side effects and symptom remission. Placement can be bilateral, in which the electric current is passed across the whole brain, or unilateral, in which the current is passed across one hemisphere of the brain. Bilateral placement seems to have greater efficacy than unilateral, but also carries greater risk of memory loss.

■ After treatment, drug therapy is usually continued, and some patients receive maintenance ECT.

■ ECT appears to work in the short term via an anticonvulsant effect mostly in the frontal lobes, and longer term via neurotrophic effects primarily in the medial temporal lobe.

Transcranial magnetic stimulation■ Transcranial magnetic stimulation (TMS) is a noninvasive method used to

stimulate small regions of the brain. During a TMS procedure, a magnetic field generator, or "coil", is placed near the head of the person receiving the treatment.

■ The coil produces small electric currents in the region of the brain just under the coil via electromagnetic induction. The coil is connected to a pulse generator, or stimulator, that delivers electric current to the coil.

■ The use of single-pulse TMS was approved by the FDA for use in migraine and repetitive TMS (rTMS) for use in treatment-resistant major depressive disorder. Evidence suggests it is useful for neuropathic pain and treatment-resistant major depressive disorder. Evidence also suggests that TMS may be useful for negative symptoms of schizophrenia and loss of function caused by stroke. As of 2014, all other investigated uses of rTMS have only possible or no clinical efficacy.

Lefaucheur, JP; et al. (2014). "Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS)". Clinical Neurophysiology 125 (11): 2150–2206.

Transcranial direct-current stimulation■ Transcranial direct current stimulation (tDCS) is a form of neurostimulation

 which uses constant, low current delivered to the brain area of interest via electrodes on the scalp.

■ It was originally developed to help patients with brain injuries such as strokes. Studies on healthy adults have failed to find evidence of cognitive improvements.

■ The way that transcranial direct current stimulation functions could be due to the plasticity concepts of long term potentiation (LTP) and long term depression (LTD) since the two share some basic similarities. Long term potentiation is the strengthening between two neurons while long term depression is the weakening between two neurons. These effects are achieved mainly through an alteration of synaptic transmission ability. 

Nitsche, M. A.; Paulus, W. (2000). "Excitability changes induced in the human motor cortex by weak transcranial direct current stimulation". The Journal of Physiology 527 (3): 633–639.

Cranial electrotherapy stimulation■ Cranial electrotherapy stimulation (CES) is a form of non-invasive

 brain stimulation that applies a small, pulsed electric current across a person's head to treat anxiety,depression, insomnia and chronic pain.

■ Electrodes are placed on the ear lobes, maxilla-occipital junction, mastoid processes

■ On June 2014, the Food and Drug Administration concluded that there is sufficient information to provide a reasonable assurance of safety and effectiveness for CES devices.

Kavirajan HC, Lueck K, Chuang K (2014). "Alternating current cranial electrotherapy stimulation (CES) for depression". Cochrane Database Syst Rev 7: CD010521.

Magnetic seizure therapy■ Magnetic seizure therapy (MST) is a proposed form

of electrotherapy and electrical brain stimulation.

■ It is currently being investigated for the treatment of treatment-resistant depression (TRD), schizophrenia and obsessive-compulsive disorder.

■ MST is stated to work by inducing seizures via magnetic fields, in contrast to ECT which does so via direct electric shocks. In contrast to (r)TMS, the stimulation rates are higher (e.g. 100 Hz at 2 T) resulting in more energy transfer. Its efficacy is yet to be determined.

"Magnetic Seizure Therapy (MST) for Treatment Resistant Depression, Schizophrenia, and Obsessive Compulsive Disorder" U.S. National Institutes of Health. 10 May 2013.

Vagal nerve stimulation■ Vagus nerve stimulation or vagal nerve stimulation (VNS) is a

medical treatment that involves delivering electrical impulses to the vagus nerve. It is used as an adjunctive treatment for certain types of intractable epilepsy and treatment-resistant depression.

■ Little is understood about exactly how vagal nerve stimulation modulates mood and seizure control but proposed mechanisms include alteration of norepinephrine release by projections of solitary tract to the locus coeruleus, elevated levels of inhibitory GABA related to vagal stimulation and inhibition of aberrant cortical activity by reticular activation system.

Ghanem, T; Early, S (2006). "Vagal nerve stimulator implantation: An otolaryngologist's perspective".Otolaryngology - Head and Neck Surgery 135 (1): 46–51. 

Implanted cortical stimulation■ CBS is a novel neurosurgical approach in which electrodes are

implanted over the surface of the cortex to provide electrical brain stimulation in a targeted superficial region.

■ This approach is being studied for treatment of conditions like stroke, tinnitus, and treatment-resistant depression.

NEUROSURGERY AND DEEP BRAIN STIMULATION

Neurosurgery■ In 1891 the first formal report of neurosurgical treatment in psychiatry

was published, describing bilateral cortical exci sions in demented and depressed patients, which yielded mixed results.

■ After four decades in which little progress was made, in 1935 John Fulton and Charles Jacobsen presented their research on primate behavior following frontal cortical ablation.

■ They observed that lobectomized chimpanzees showed reduction in "experimental neurosis" and were less fearful, while retaining an ability to perform complex tasks.

Neurosurgery

■ Egaz Moniz, a renowned Por tuguese neurologist, pioneered prefrontal leukotomy in collabo ration with his neurosurgical colleague Almeida Lima.

■ First by using absolute alcohol injections and subsequently by mechani cal means with a leukotome, Moniz and Lima performed "psy chosurgery" on 20 severely ill institutionalized patients; 14 were said to have exhibited worthwhile improvement.

Neurosurgery■ All the forms of psychosurgery in use today (or used in recent years) target

the limbic system, which involves structures such as the amygdala, hippocampus, certain thalamic and hypothalamic nuclei, prefrontal and orbitofrontal cortex, and cingulate gyrus — all connected by fibre pathways and thought to play a part in the regulation of emotion.

■ There is no international consensus on the best target site.

■ Anterior cingulotomy was first used by Hugh Cairns in the UK, and developed in the US by H.T. Ballantine jnr. In recent decades it has been the most commonly used psychosurgical procedure in the US. The target site is the anterior cingulate cortex; the operation disconnects the thalamic and posterior frontal regions and damages the anterior cingulate region

Neurosurgery■ Anterior capsulotomy was developed in Sweden, where it became the

most frequently used procedure. It is also used in Scotland and Canada. The aim of the operation is to disconnect the orbitofrontal cortex and thalamic nuclei.

■ Subcaudate tractotomy was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra-orbital part of the frontal lobe.

■ Limbic leucotomy is a combination of subcaudate tractotomy and anterior cingulotomy. It was used at Atkinson Morley Hospital London in the 1990s and also at Massachusetts General Hospital.

Neurosurgery■ Amygdalotomy, which targets the amygdala, was developed as a

treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the Medical College of Georgia.

■ Success rates for anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy in treating depression and OCD have been reported as between 25 and 70 per cent.

Mashour, G.A.; Walker, E.E.; Martuza, R.L. (2005). "Psychosurgery: past, present and future". Brain Research Review 48 (3): 409–18.

Deep Brain Stimulation■ Deep brain stimulation (DBS) is a neurosurgical procedure introduced

in 1987, involving the implantation of a medical device called a neurostimulator (sometimes referred to as a 'brain pacemaker'), which sends electrical impulses, through implanted electrodes, to specific parts of the brain (brain nucleus) for the treatment of movement and affective disorders.

■ DBS in select brain regions has provided therapeutic benefits for otherwise-treatment-resistant movement and affective disorders such as Parkinson's disease, essential tremor, dystonia, chronic pain, major depression and obsessive–compulsive disorder (OCD).

Kringelbach ML, Jenkinson N, Owen SLF, Aziz TZ (2007). "Translational principles of deep brain stimulation". Nature Reviews Neuroscience 8 (8): 623–635.

Deep Brain Stimulation■ The deep brain stimulation system consists of three components: the

implanted pulse generator (IPG), the lead, and the extension.

■ The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain to interfere with neural activity at the target site. The lead is a coiled wire insulated in polyurethane with four platinum iridium electrodes and is placed in one or two different nuclei of the brain.

■ The lead is connected to the IPG by the extension, an insulated wire that runs below the skin, from the head, down the side of the neck, behind the ear to the IPG, which is placed subcutaneously below the clavicle or, in some cases, the abdomen.

Deep Brain Stimulation■ A recently proposed target of DBS intervention in depression is the

superolateral branch of the medial forebrain bundle (slMFB), its stimulation lead to surprisingly rapid antidepressant effects in very treatment resistant patients.

Schlaepfer, TE; et al. (2013). "Rapid effects of deep brain stimulation for treatment-resistant major depression". Biological Psychiatry 73 (12): 1204–12.

REFERENCES■ KAPLAN AND SADOCK’S SYNOPSIS OF PSYCHIATRY, 11TH EDITION■ VARIOUS ONLINE SOURCES AS MENTIONED IN THE SLIDES

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