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PubMed2004

Behavioral interventions for dual-diagnosis patients.

Dual diagnosis patients come to treatment with a variety of deficits,talents, and motivations. A biopsychosocial treatment plan involves multiple interventions, including medications, medical treatment, psychotherapy, family therapy, housing, and vocational rehabilitation. Treatment must be individualized and integrated, and this requires collaboration among a variety of health caregivers. There is empirical evidence that dual-diagnosis patients can be helped to stabilize, to remain in the community,and even to enter the workforce. Behavioral interventions are key ingredients to integrated and comprehensive treatment planning. There is no single model for dual disorders that explains why substance use and psychiatric illness co-occur so frequently. Mueser et al described four theoretical models accounting for the increased rates of comorbidity between psychiatric disorders and substance use disorders. They suggested that there could be a common factor that accounts for both, primary psychiatric disorder causing secondary substance abuse, primary substance abuse causing secondary psychiatric disorder, or a bidirectional problem, where each contributes to the other. There is evidence for each, although some are more compelling than others, and none is so compelling that it stands alone. Although family studies and genetic research could explain the common factor, no common gene has appeared. Antisocial personality disorder has been associated with very high rates of substance use disorders and mental illness; however, its prevalence is too low to explain most of the co-occurring phenomena. Common neurobiology, specifically the dopamine-releasing neurons in the mesolimbic system, also may be involved in mental illness, but this is not compelling at the moment. The Self-medication model is very appealing to mental health professionals, as an explanation for the secondary substance abuse model. Mueser et al suggest that three lines of evidence would be present to support this explanation: (1) patients would report beneficial effects of substance use on their symptoms; (2) epidemiology would report that a specific substance would be used by specific psychiatric disorders, and (3) psychiatric patients with severe symptoms would be more likely to abuse substances than those with mild symptoms. Unfortunately the research data do not support these. The primary substance abuse causing secondary psychiatric disorder model could be explained by neuronal kindling from substance-induced disorders. Patients who develop the psychiatric disorder after the substance use disorder do have a course of illness similar to those with a psychiatric disorder, but without substance use disorder. The bidirectional model is consistent with the tendency of disturbed teenagers to socialize with youth using alcohol and drugs; however, this model has not been tested rigorously in research studies. With such a disparate set of models, behavior interventions are conceptualized best as a multi-component program, a treatment plan that generates a problem list and devises an intervention to respond to each member of the list. This requires a talented, multi-disciplinary team or network that can assess carefully and package the interventions creatively, and dose the treatment components empathically to fit the patient's tolerance, motivation, and abilities.

Behavior Therapy↗
PubMed2000

Research on dialectical behavior therapy for patients with borderline personality disorder.

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. Evidence suggests that additional research is warranted to examine which components of DBT contribute to outcomes. Although preliminary, skills coaching seems to be a crucial ingredient in producing reductions in parasuicidal behavior, and specific strategies (e.g., validation, balance of change, and acceptance interventions) may play an important role in positive behavioral change. Several investigators are evaluating the efficacy of DBT. For example, Asberg et al at the Karolinska Institute in Sweden have begun a pilot study comparing DBT for women who have made multiple suicide attempts to transference focus psychotherapy, a psychodynamic therapy developed by Kernberg. They have planned a randomized clinical trial to compare DBT and transference focus psychotherapy with TAU in the community. van den Bosch has completed a randomized clinical trial for women who met criteria for BPD and substance abuse comparing DBT-S with TAU. Lynch is conducting a randomized clinical trial examining the efficacy of DBT skills training plus medication versus medication only for the treatment of moderate to severe depression in the elderly. Results from these studies should become available over the next several years, providing further empiric evidence by which to evaluate the efficacy of DBT. Additional development of DBT seems warranted to improve its efficacy, and additional investigation is needed to establish its effectiveness in public health settings. Analyses from existing data sets of factors that predict treatment response and elements of the treatment that contribute to outcome are needed. Also, longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains are needed. Because DBT has been adopted in a variety of clinical settings, effectiveness studies are needed. Given the difficulty of conducting treatment research with chronically suicidal individuals, perhaps the largest challenge to further treatment development is recruiting young investigators who are willing to conduct research in this area. Nevertheless, in the 6 years since the treatment manuals were published, DBT seems to be a step toward more effective treatment for severely multidisordered patients.

Behavior Therapy↗
PubMed2003

Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate.

BACKGROUND: Sleep-related eating disorder (SRED) and nocturnal eating syndrome (NES) combine features of sleep disorders and eating disorders. Treatment of these nocturnal eating behaviors has been directed towards underlying identifiable sleep or eating disorders using dopaminergic or opioid agonists, as well as anorectic agents, at times with the addition of sedatives. METHODS: Two patients with SRED and two with NES, who had failed multiple previous trials of pharmacotherapy and psychotherapy, were treated in a naturalistic, open-label fashion with topiramate at night. Reduction in nocturnal eating was graded based on self-report. Weight was computed at the outset of, and during, topiramate treatment. RESULTS: One patient with NES had a complete elimination of nocturnal eating with topiramate, two patients (one with NES, one with SRED) had a marked response, and one patient (with SRED) had a moderate response. Mean dose was 218 mg, though three patients noted an improvement at 100 mg. Notable weight loss was observed in all patients (mean of 11.1 kg). Benefits of topiramate treatment have been maintained for a mean period of 8.5 months. CONCLUSIONS: Topiramate may be of benefit for patients with NES or SRED in reducing nocturnal eating, improving nocturnal sleep, and producing weight loss.

Adult↗
PubMed2001

Idiopathic environmental intolerances (formerly multiple chemical sensitivity) psychiatric perspectives.

Idiopathic environmental intolerances (IEI)/multiple chemical sensitivity (MCS) is characterized by various somatic symptoms which cannot be explained organically, but are attributed to the influences of toxic environmental chemicals in low, usually harmless doses. In the absence of a widely accepted definition of IEI, contradictory aetiological hypotheses and therapeutic suggestions are discussed. Some authors doubt the existence of IEI/MCS as a disease entity of its own. The label IEI does not implicate neither a diagnosis of somatic disease nor that it is caused by an avoidable exposure. Many IEI patients suffer from psychiatric diseases. A majority of them can be diagnosed as somatoform disorders. Consequently, psychiatric therapies could be effective. This review describes the current knowledge about IEI/MCS, outlines a diagnostic algorithm and a psychotherapeutic concept for variants of IEI understood as a somatoform disorder.

Comorbidity↗
PubMed2004

Treatment of depression in cancer.

Depression occurs in about 15% of the general population and is at least two to three times more common in patients with cancer. Depression is often difficult to diagnose in these patients because of the complexity and constraints of cancer care, patient and family reluctance to acknowledge distress, and the presence of multiple other symptoms. Both antidepressants and psychotherapy are effective in treating depression in patients with cancer, much like in patients with other significant medical problems. Precise assessments of the benefits of treating depression in these patients are important in weighing them against the costs and potential adverse effects. Such estimates are limited by a paucity of randomized, placebo-controlled trials and methodological problems in the existing studies that reflect some of the clinical difficulties in case-finding, treatment, and follow-up of patients with cancer. The existing body of research about depression in cancer patients is extremely limited in terms of the number of studies published and the number of total patients reported over the last 30 years. Moreover, these limited data may not generalize well because of high rates of patient dropout and the very limited enrollment of children, adolescents, older adults, and minority groups. There is an emerging trend toward simplifying the assessment of depression in outpatient cancer care settings and studying depression therapies in cohorts of patients with cancer other than those with fully characterized depressive disorders.

Adolescent↗
PubMed1992

The outpatient treatment of depression. Implications of outcome research for clinical practice.

Multiple studies have demonstrated that individual psychotherapy, pharmacotherapy, and the two in combination are all effective treatments for depressed outpatients. However, the implications of these data for clinical practice have been incompletely considered, and the often drawn mistaken conclusion is that they support routine treatment with psychotherapy and pharmacotherapy together. Analyses of treatment success rates, treatment failure rates, and treatment dropout rates indicate that combined treatment offers no advantage over treatment with psychotherapy alone and only modest advantage over treatment with pharmacotherapy alone. Routine use of combined treatment, therefore, exposes patients to unnecessary costs and side effects. The data suggest that psychotherapy alone should usually be the initial treatment.

Ambulatory Care↗
PubMedDate not supplied

Haven Hugs & Bugs. An innovative multiple-family weekend intervention for bereaved children, adolescents and adults.

This article describes the development and implementation of a unique, two-day therapeutic program for bereaved families. Issues relevant to program design are presented along with evaluation results. The family focus, the therapeutic value of nature, and the relationship of this program to Multiple Family Therapy, time-limited psychotherapy, and wilderness, camping, or recreation therapy approaches are discussed. Questions and suggestions for future evaluation research are noted. The high potential therapeutic and cost-effectiveness of such innovative approaches to bereavement counseling should motivate further program development and outcome research. Information on other weekend bereavement programs is appended.

Adolescent↗
PubMed2001

[Depression in the elderly. Principles of treatment].

DRUG THERAPY: Drug therapy must be reassessed regularly to avoid overdosing or poor observance. Use of multiple drugs must be carefully monitored. PSYCHOTHERAPY: Listening to the patient and establishing an understanding friendly relationship are essential to successful psychotherapy in the depressed elderly. SUPPORT: Repulsion is common because old age evokes death. The reactions of family and friends may take on many forms, sometimes leading to counter-transfer. EIGHT SIMPLE RULES FOR PRESCRIPTION: Ask key questions. Treat what is essential. Prescribe few drugs starting at low dose. Check observance. Favor good diet and hygiene. Help the patient accept the aging process. Avoid pseudo placebos. Use appropriate dose timing.

Aged↗
PubMed1986

Predictors of psychotherapy outcome for children at a community mental health center.

This study assessed the utility of multiple predictors of outcome for 268 child clients and their families who received psychotherapy at a community mental health center for children. Outcome was measured by the number of therapy sessions attended, the length of therapy, and improvement ratings of the child and family made by independent judges. Regression analyses revealed that the strongest predictors of outcome were previous exposure to therapy, therapist type (permanent professional staff vs. intern), family constellation, therapist experience, and referral source. Implications for treatment planning and future research are discussed.

Child↗
PubMed2003

[Contribution of interventional studies of family caregivers of patients with Alzheimer's disease].

COPING WITH CHRONIC STRESS: Family members are the first-line caregivers for elderly patients with dementia living at home. Giving care to a demented patient has an important impact on the mood, quality-of-life, physical and psychological health of family aids: frequent episodes of depression, immunity disorders, altered capacity for wound healing, increased consumption of psychotropic drugs and increased mortality. INTERVENTIONS FOR FAMILY AIDS: Helping family caregivers is an integral part of modern care for Alzheimer's disease: social and financial support, medical assistance. Several specific interventional programs have been proposed, either alone or as part of a multiple-component program: educational sessions, group support, psychotherapy, respite care. NECESSARY DEVELOPMENTS: The results of studies assessing the effects of different types of interventions have shown that they reduce the cure giver's burden and depression, and patient's symptoms while improving the caregiver's feeling of well-being and his/her knowledge, and competence. Multiple-component interventions are the most effective. Research in this area should be developed in France, including an examination of the feasibility of such studies which are highly dependent on the cultural and social context of care as well as on the efficacy and the cost of the interventions.

Adaptation, Psychological↗
PubMed1986

Treatment progress in 20 patients with multiple personality disorder.

Attempts to follow the treatment progress of patients with multiple personality have been limited to a few single case studies and, in the only large series, to those most successfully treated. This study followed the treatment progress of 20 patients for a mean of 39 months after intake. The study included a detailed history, neurological examination, and psychological testing on each patient. At follow-up each patient was interviewed and a questionnaire was completed by his or her therapist to assess treatment response. Although nine patients achieved partial or full integration, complete integration was maintained by only five. During therapy the unintegrated patients experienced emotional trauma at approximately twice the rate as did the patients who eventually became integrated. Psychodynamic psychotherapy and hypnosis were the most widely prescribed therapies. The improvement in multiple personality appeared to proceed in a stepwise fashion from acceptance of the diagnosis to integration. The progress of therapy was hindered most commonly by the overuse of the mental mechanisms of repression and denial, the continued utilization of secrecy, which began during child abuse, and the production of numerous crises. The most common countertransferences included anger, exasperation, and emotional exhaustion. Although the psychotherapy of patients with multiple personality is tedious and time consuming, it can be eminently successful if the patient and therapist persevere.

Adolescent↗
PubMed1996

Termination in group psychotherapy from the perspectives of contemporary object relations theory and self psychology.

Throughout the development of object relations theory and self psychology, the importance of attachments, availability, absences, limitations, and endings have been factors that have informed theory and practice. This article examines the multiple meanings and impacts of terminations in group psychotherapy at the intrapsychic, interpersonal, and group-as-a-whole levels, from the perspective of contemporary object relations theory and self psychology. Emphasis is placed on the initiation of a mourning process, with the dynamics of guilt, shame, and aggression toward objects who are separate or inaccessible, and the experience of a shortcoming or absence, associated with a loss of self-object oneness, soothing, and idealization from the narcissistic sector of the personality. Therapeutic opportunities afforded by terminations and the importance of resolving countertransference reactions are highlighted.

Adult↗
PubMed2006

Multiple-role dilemmas for military mental health care providers.

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.

Conflict of Interest↗
PubMed1988

Update on behavioral treatments for substance abuse.

In the past five years there has been an encouraging increase in the amount and quality of research on behavioral treatments for substance abuse. Some of the most promising approaches combine behavioral treatments with each other (e.g., relapse prevention and cue exposure) or with other forms of treatment (e.g., psychotherapy), attempting to maximize impact on the multiple determinants of drug use. We are fast approaching the time when a patient may be systematically evaluated to develop a profile of vulnerabilities (cue responsivity, psychiatric symptoms, etc.) to rationally determine the treatment or combination of treatments of greatest potential benefit.

Behavior Therapy↗
PubMed2001

[Phobic neuroses presenting as "intolerance reaction of the skin"].

Intolerance reaction of the skin refers to multiple reaction patterns, including toxic, allergic, pseudo-allergic and even psychiatric mechanisms. In our case, a patient was diagnosed for years as having "multiple allergies", but except for a documented contact allergy to a local anesthetic, her underlying disease was panic disorder with multiple phobias. Using this case study with one year follow-up, hypotheses are discussed about effective psychotherapy in patients with intolerance reactions of the skin. Differential indications are explored with reference to the latest investigative results in psychoneuroimmunology. In this patient, psychotherapy helped the phobias and eliminated her conviction that she had multiple allergies. In addition, the positive pre-therapy allergy testing was not reproducible. The dermatologist should not expect such patients to present with phobias, because they frequently shift their phobic anxiety into the fear of allergic reactions to escape from the label of having psychiatric disease. Such patients should receive psychotherapy if they begin to generalize their avoidance behavior and limit their social contacts.

Diagnosis, Differential↗
PubMed2001

A survey of prescribing preferences in the treatment of refractory depression: recent trends.

The objective of this study was to gather data from a large group of clinicians on antidepressant prescribing practices in the treatment of refractory depression. Eight hundred and thirty-five clinicians about to attend the annual Massachusetts General Hospital psychopharmacology review course were asked to respond to a brief questionnaire regarding a hypothetical clinical case vignette. The case was of a patient who suffered from a new onset, unipolar, nonpsychotic, severe major depressive episode. Three hundred and four (36%) clinicians agreed to participate and filled out our questionnaire. Of the respondents, 260 (85.5%) indicated their preference for an initial treatment that combined medication and psychotherapy, as opposed to either modality alone. Furthermore, given this patient's nonresponse to two adequate selective serotonin reuptake inhibitor (SSRI) trials and one atypical antidepressant trial over an 8-month period, 39.8% of respondents indicated venlafaxine monotherapy as their next choice, whereas combining antidepressants (20.1%) and augmentation (18.4%) were the second and third most preferred treatment choices at this time point. Further on in the course of treatment, with the patient not having responded to any interventions during a 16-month period, 80.9% of survey respondents indicated electroconvulsant therapy (ECT) as their next preference. Among 304 clinicians surveyed, a combination of therapy and medication is the most preferred choice for treating severely depressed outpatients with new onset depression. Switching to venlafaxine, using two antidepressants together, and augmentation of an antidepressant regimen with a second agent accounted for 78.3% of respondents' preferences when faced with treating a depressed patient who had not responded to two adequate SSRI trials and one adequate atypical antidepressant trial. Of the respondents, 80.9% indicated ECT as a treatment preference after 16 months of multiple failed medication trials and nonresponse to psychotherapy. Further research is necessary to elucidate the factors that influence clinicians' reasoning for selecting one strategy over another.

Antidepressive Agents↗
PubMed1998

Mental health and psychic structure: an empirical study.

Psychodynamic clinicians cite psychic structure and structural changes observed in treatment as sources of important information about unconscious psychological processes and configurations. Empirical studies have had difficulty demonstrating that psychic structure measures something different from psychiatric symptoms and everyday functioning. This study examined the relationship between psychic structure and mental health using the Health-Sickness Rating Scale (HSRS) to measure mental health and two different measures to assess psychic structure: Kernberg's personality organization (PO) and Wallerstein's Scales of Psychological Capacities (PSYCAP). Bivariate correlations and multiple regression analyses were computed based on ratings for 124 psychiatric inpatients and psychotherapy clients. Correlations showed that mental health and psychic structure are substantially interrelated, and multiple regression analyses indicated that 44% of the variance of HSRS is explained by psychic structure measured with the two methods taken together. The findings provide some support for a general factor of mental health and psychic structure and a "pure" component of psychic structure that is independent from mental health. Different factor-analytic models for understanding the relationship between mental health and psychic structure are discussed.

Adaptation, Psychological↗