Therapy Modalities Mariel Lougee, PGY1 1/20/16 Doctor: Have you tried therapy? Are you Interested? What is a patients perspective on therapy Freud Lying on a couch Group therapy Talking about your relationship with your mother TV/Movie portrayal Only talking about feelings Judgement Shrink Meds Different Therapy Modalities...in brief CBT DBT Prolonged Exposure Therapy Group Therapy CBT: Cognitive Behavioral therapy Time-limited, goal-oriented psychotherapy Targets changes in symptoms of disorders to reduce functional impairment and improve quality of life Who Benefits? anxiety depression PTSD ADHD autism OCD/tic disorders eating disorders insomnia Level B evidence: medications are primary treatment for bipolar and schizophrenia but CBT can give additional benefit Level A evidence: CBT is effective for mild to moderate depression, anxiety, PTSD, OCD, tic disorders, personality disorders, insomnia, and ADHD I cannot connect with anyone...target change in this emotion - could challenge pt to give examples of times when they did engage with others. pt feels less hopeless and that this belief/thought was wrong and then reach out to engage a friend How could it help with Medical Comorbidities A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. 87 adults with unipolar depression and uncontrolled DM2 had CBT along with usual therapy for their depression. RESULTS: Immediately after acute treatment (4 months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI to , P = 0.000), 24.3 percentage points higher medication adherence at 4/8/12 mo 30.2% points greater SMBG adherence through glucometer downloads, 16.9% at 4/8/12 mo 6.44% points lower depression scores on the Montgomery-Asberg Depression Rating Scale, 16.9% 0.74% points lower on the Clinical Global Impression (95% CI , P = 0.01) 0.72% units lower A1C (95% CI , P = 0.001) relative to ETAU,.63% improvement at 4/8/12 mo CONCLUSIONS: CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression. Interestingly no significant improvement in depression. But where do I find someone?? DBT: Dialectical Behavioral Therapy DBT was originally developed in the 1980s by Marsha Linehan, a psychologist at the University of Washington. DBT has four major components: 1. Weekly individual (one-to-one) therapy 2. Weekly skills-training sessions, usually in the form of groups 3. As-needed consultation between client and therapist outside of sessions 4. Weekly therapist consultation meeting in which DBT therapists meet to discuss their DBT cases The skills-training component of DBT involves teaching the individual specific skills designed to help improve their life in four major areas: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. Who Benefits from DBT? DBT initially was created to treat chronic suicidality Now DBT is commonly used with BDP Eating disorders (specifically bulimia and binge eating disorders) Self-injurious behavior Treatment-resistant depression Dual diagnosis patients (substance abuse and mental health diagnoses) How does DBT work? How does DBT work in the brain? Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. Event-related fMRI was obtained pre- and post-12-months of standard-DBT in unmedicated BPD patients. Healthy controls (HCs) were studied as a benchmark for normal amygdala activity and change over time (n = 11 per diagnostic-group). During each scan, participants viewed an intermixed series of unpleasant, neutral and pleasant pictures presented twice (novel, repeat). Change in emotion regulation was measured with the Difficulty in Emotion Regulation (DERS) scale. RESULTS: fMRI results showed the predicted Group Time interaction: compared with HCs, BPD patients exhibited decreased amygdala activation with treatment. This post-treatment amygdala reduction in BPD was observed for all three pictures types, but particularly marked in the left hemisphere and during repeated-emotional pictures. CONCLUSION: These findings have promising treatment implications and support the notion that DBT targets amygdala hyperactivity-part of the disturbed neural circuitry underlying emotional dysregulation in BPD. Future work includes examining how DBT-induced amygdala changes interact with frontal-lobe regions implicated in emotion regulation. DBT Resources KP Richmond DBT/Dept of Psychiatry 901 Nevin Ave Richmond, CA Phone: (510) Fax: (510) Program(s): Outpatient Population(s): Adult,Substance Use Disorders Mt. Diablo Psychological Services 91 Gregory Lane, Ste 19 Pleasant Hill, CA Phone: (925) Fax: (925) Website:Program(s): Outpatient Population(s): Adolescents,Adult,Eating Disorders,Substance Use Disorders Oakland DBT and Mindfulness Center 5767 Broadway, Suite 101 Oakland, CA Phone: (510) Website:Program(s): Outpatient Population(s): Adolescents,Adult Clearwater Counseling and Assessment Services th St. Oakland, CA Phone: (510) Fax: (510) Website:Program(s): Outpatient Population(s): Adolescents,Adult,Eating Disorders,Substance Use Disorders DBT at UCSF 401 Parnassus Ave San Francisco, CA Phone: (415) Website:Program(s): Outpatient Population(s): Adolescents SF Bay DBT Collaborative San Francisco, CA Phone: (415) Website: sfbaydbt.comsfbaydbt.com Program(s): Outpatient Population(s): Adolescents,Adult,Eating Disorders,Substance Use Disorders Prolonged Exposure Therapy PE was developed by Edna Foa, PhD, Director of the Center for the Treatment and Study of Anxiety. Who Benefits? Initially used for veterans returning from war with significant PTSD Has also been used in specific phobias, PTSD in non-veterans, and anxiety In vivo exposure: Directly facing a feared object, situation, or activity in real life. For example, someone with a fear of snakes might be instructed to handle a snake, or someone with social anxiety might be instructed to give a speech in front of an audience. Imaginal exposure: Vividly imagining the feared object, situation, or activity. For example, someone with Posttraumatic Stress Disorder might be asked to recall and describe his or her traumatic experience in order to reduce feelings of fear. Virtual reality exposure: In some cases, virtual reality technology can be used when in vivo exposure is not practical. For example, someone with a fear of flying might take a virtual flight in the psychologist's office, using equipment that provides the sights, sounds, and smells of an airplane. Interoceptive exposure: Deliberately bringing on physical sensations that are harmless, yet feared. For example, someone with Panic Disorder might be instructed to run in place in order to make his or her heart speed up, and therefore learn that this sensation is not dangerous. From the APA definition of Exposure Therapy: 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. PE is effective in reducing symptoms of both PTSD (pre-post d = 0.87) and depression (pre-post d = 0.66) Ways that PE Helps Habituation Extinction Self-efficacy Emotional processing Group Therapy Different types of group therapy CBT/DBT can be done in group form Group visits/therapy for medical conditions Prenatal, Diabetes, Chronic Pain Groups for different psychiatric disorders Depression/Substance Abuse/Grief Group therapy and Medical Comorbidities The efficacy of a multidisciplinary group program for patients with refractory chronic pain. 46 patients with medication refractory chronic pain were started on a 9 week behavioral therapy + exercises group for pain. A number of measures (eg, pain intensity, disability, catastrophizing thoughts) showed significant improvements after intervention (P