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psychotherapist GP

Winter 2011 Vol. 18, #1

Newsletter of the General Practice Psychotherapy Association

From the Board - January 2011 · By Julie Webb MD, CGPP

As you read this the New Year has begun, a few resolutions will have already gone by the wayside, and a few more will still be inspiring us. Here is some of the work your GPPA Board has undertaken during the fall. We continue to explore "a third path" that members may be able to use to enter continuing medical education for maintenance of accreditation with the College of Physicians and Surgeons. We already have a good method for monitoring these credits, and we encourage members to keep their educational aendance certificates for six years. Our president Muriel van Lierop and I have taken our Policies and Procedure Manual through a major review, with the help of the Commiees and the patience of the Board Members who have overseen this. We now have the Manual in digital format which will make it much easier to access and review in a timely fashion. This will help when we ask ourselves "what comes next?" or "what are the rules about..?" Later in this issue, read all about the Visioning Day scheduled for Feb 27, 2011. This day will be an excellent opportunity for evaluating and planning. We will work with a facilitator to move forward with the great ideas generated at the 2010 Conference and provide direction for the Association. If you would like to aend please contact the Board Office. And speaking of vision, we need volunteers to join commiees. Even if all you can do is a small job, together we learn from, and help each other. It's a privilege and encouragement to spend time with other therapists, and we want as many voices as possible working to strengthen the organization. If you would like to really get involved, then there may be a place on the Board for you. Feel free to contact me by email if you would like to know more about volunteering. I promise -- no obligation! May you have a wonderful solstice season, enjoying the wealth of spirit available in these winter days.

MARK YOUR CALENDAR GPPA 2011 CONFERENCE AND ANNUAL GENERAL MEETING May 27/28, 2011

Radisson Admiral Hotel Toronto, Ontario

Inside

Intensive Short-Term Dynamic Psychotherapy ................................................................. 3 Visioning Exercise and Meeting ............. 5 Management of Obsessive Compulsive Disorder ................................................... 7 Book Review: The Impact of Early Life Trauma on Health and Disease .............. .11

From the Editor · By Howard Schneider MD, CGPP, CCFP

The theme of the upcoming GPPA conference later this year is "Trauma and Aachment ­ Foundations for a Healing Paradigm." We thus lead off this issue of the GP Psychotherapist with an article by University of British Columbia psychiatrist Robert Tarzwell on Intensive Short-Term Dynamic Psychotherapy (ISTDP). ISTDP focuses on complex, mixed feelings from aachment-based trauma, usually in relation to aachment figures from the early phase of life. In the following article Edward Leyton, Victoria Winterton, Howard Eisenberg and Muriel J. van Lierop describe a GPPA Visioning Meeting set for Sunday, February 27, 2011, to be held at the OMA Headquarters at 150 Bloor Street West, Suite 900, Toronto. At the 2010 GPPA Conference Howard led a plenary session Envisioning a More Desirable Future for GP Psychotherapy. Edward and colleagues point out in their article that the vitality of the GPPA is very much dependent upon the vitality of its members and the input that they have into the future of the GPPA. They invite all GPPA members to aend the Visioning Meeting. As I wrote last year, there is a bit of a lull in GPPA educational activities leading up to the Annual Conference and so last year the GP-Psychotherapist inaugurated a Winter Educational Teleconference Series. In collaboration with the GPPA Education Commiee we are pleased to continue this series of hour-long educational teleconferences in February, March and April 2011. The teleconferences are held on Wednesday evenings from 8 ­ 9 PM with the following tentative dates: February 2 8-9 PM ­ Sex Therapy - Victoria Winterton February 23 8-9 PM ­ The Management of OCD ­ Howard Schneider March 30 8-9 PM ­ Trauma & Dissociation ­ Harry Zeit April 13 8-9 PM ­ Book Club: "When the Body Says No" by Gabor Mate -- Jody Bowle-Evans and Julie Webb There is no sponsorship of this year's teleconferences and so there will be a very small charge for each one. Please register with Carol at [email protected] if you are interested in participating. (The capacity for each offering is about fieen registrants.) Teleconference dial-in information will be sent to registrants. For each teleconference, you can claim 1 hour of CCI or CE credits. The GP Psychotherapist continues with an article by myself on the management of ObsessiveCompulsive Disorder, which, yes, ties in to the Educational Teleconference for those aending. In considering all illnesses (both mental and physical), the WHO (World Health Organization) considers formal OCD to actually be the tenth leading cause of disability. OCD has a lifetime prevalence of 23% of the general population in terms of meeting the full DSM-IV criteria. However, approximately one-quarter of the general population will have lessor amounts of obsessive and compulsive symptoms. ObsessiveCompulsive Disorder is a chronic, disabling disorder. With appropriate treatment many patients can achieve enough symptom improvement to dramatically increase the quality of their lives.As medical psychotherapists we are in an ideal position to possess the knowledge and skills to treat this complex disorder with the counselling, psychoeducational, psychotherapeutic, psychopharmacological and medical interventions that are required of the successful practitioner. At this time, the first-line treatment of OCD in almost all cases is Cognitive Behavioral Therapy (CBT). Of interest, while in ISTDP (Intensive Short-Term Dynamic Psychotherapy) unconscious emotions lead to faulty cognitions, in CBT this is reversed ­ the basis of cognitive therapy is that faulty cognitions cause the emotional disorder. However, in studies both CBT and ISTDP have shown good clinical results. Perhaps cognitive thoughts and feelings indeed flow in both directions. This issue of the GP Psychotherapist then concludes with a Book Review by Catherine Low on "Impact of Early Life Trauma on Health and Disease ­ The Hidden Epidemic" edited by Ruth A. Lanius, Eric Vermeen and Clare Pain. Ruth Lanius and Clare Pain will both be presenting Keynote addresses at the upcoming GPPA Annual Conference. A healthy and happy New Year to all members of the GPPA.

GP Psychotherapist

ISSN 1918-381X

Editor: Howard Schneider

[email protected]

Assistant Editor/Science Editor: Norman Steinhart

General Practice Psychotherapy Association 312 Oakwood Court Newmarket, ON L3Y 3C8 Tel: 416-410-6644, Fax: 1-866-328-7974 [email protected], www.gppaonline.ca

The GPPA (General Practice Psychotherapy Association) publishes the GP Psychotherapist three times a year. Submissions will be accepted up to the following dates: Winter Issue - November 2 Spring/Summer Issue - March 2 Fall Issue - July 2 For leers and articles submied, the editor reserves the right to edit content for the purpose of clarity. Please submit articles to: [email protected]

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psychotherapist GP

Winter 2011

Intensive Short-Term Dynamic Psychotherapy

· By Robert Tarzwell, MD, FRCPC - Clinical Instructor, Division of Adult Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada Intensive Short-Term Dynamic Psychotherapy (ISTDP) is a therapeutic technique developed by psychiatrist Habib Davanloo of McGill University (1, 2, 3). The essence of ISTDP is to help patients overcome their conscious and unconscious resistance to their true thoughts and feelings about the present and past. It focuses on complex, mixed feelings from aachmentbased trauma, usually in relation to aachment figures from the early phase of life. These feelings initially generated in traumatic situations become blocked from the child's awareness but retain dynamic power in the individual's life, manifested as psychological symptoms, functional symptoms like headache or diarrhea, and characterological difficulties in relationships. Interacting in such a way that the patient no longer feels the need to block, thereby allowing direct access to feeling, is the primary task of the therapist. An ISTDP session begins with a phase of inquiry into problem areas. These are explored with an eye on the patient's level of emotional activation. Patients are guided toward painful and embarrassing problem-areas, always with their consent, but nevertheless, in many cases, feelings begin to activate as a result of this process. The patient may appreciate the therapist's efforts to become emotionally close but also experiences irritation at the relentless effort and refusal to be put off. As resistance arises, the therapist begins the process of tilting it toward the transference relationship, oen by simply pointing it out: "You smile and sigh when I ask you about your sexual life." When conducted in a sensitive and skillful way, resistance gradually crystallizes

Winter 2011

in the transference, manifested as an apparent emotional disengagement with what should be intensely affect-laden areas. The manifestation may also take the form of anxiety, visible as tension in voluntary muscle which the patient may not even be aware of. As transference feelings and resistance rise, the therapist explicitly introduces the transference, usually with the question, "How do you feel right now?" This begins the phase of pressure in the transference. The goal is to continue to increase the intensity of complex transference feelings and transference resistance. Patients unable to respond to inquiry may need the process to move directly to the transference. In any case, the therapist then proceeds to make the transference even more explicit by asking, "How are you feeling toward me?" The patient's manifestation of resistance and anxiety is closely monitored. Some patients are able to achieve direct access to their anxiety-laden, painful feelings with these interventions, but many require further intervention. The ultimate intervention of ISTDP is the Head-On Collision with the resistance in the transference. The therapist reminds the patient that seeking help with problems is a free decision. Next, the therapist points out the destructive consequences of continuing to employ character defenses ­ perpetuation of the life of suffering. The possibility of success and failure is explicitly examined, with the reminder that both belong to the patient, and there is a limit to what the therapist can do. Finally, the therapist calls on the therapeutic alliance to exert a supreme effort

of will against the resistance, in favour of health. The goal of this intervention is to trigger an intrapsychic crisis through which the patient comes to realize that success or failure really is not up to the therapist. This deactivates the transferential omnipotence, and when successful, is the triggering mechanism unlocking the unconscious transference feelings which can then be directly experienced and explored. Sixty years of video-based research over thousands of cases demonstrate that these feelings oen have a very precise sequence. First, the patient becomes aware of rage toward the therapist. This is intensely felt and arises in a specific neurobiological sequence, from the pelvis, into the abdomen and chest, and down the arms, experienced as heat and power. The therapist encourages the patient to experience this rage-filled impulse directly, rather than continuing to bury it under anxiety. The therapist then encourages the patient to unleash the rage in fantasy and mentally depict what would happen to the therapist. The rage oen has a quality which is violent, murderous, or even torturous, correlating strongly with the age and severity of the initial trauma. Aer exploring the rage-filled fantasy, with full somatic experiencing of emotion, the patient is then confronted with the question, "Now, how do you feel when you look to my eyes aer such a vicious aack?" This oen leads to immediate and spontaneous outpouring of immense, previously unconscious, guilt, along with an image transfer to the genetic figure. The patient

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Intensive Short-Term Dynamic Psychotherapy (cont'd)

is in a phase which Davanloo has called "Dreaming while awake." The eyes of the therapist become the eyes of the mother (or other aachment figure), and intense emotion is experienced including guilt about the rage, intense love for the aachment figure, and intense grief about the trauma, together with derepression of significant memories from the initial traumatic incident. The key therapeutic ingredient, again based on video-based research, is direct experiencing of unconscious guilt, leading to multidimensional symptom and character changes. Guilt also has a specific neurobiological concomitant: painful constriction in the larynx and the medial 1st, 2nd, and 3rd intercostals, with spontaneous, intense sobbing which comes in waves. ISTDP training formats include an introductory video-tape based demonstration of technical and metapsychological principles, core supervision groups where videotaped psychotherapy sessions are reviewed, and closed-circuit training where therapists can receive immediate feedback during a live interview, including exploration of their own unconscious factors which may be hindering the therapeutic process. At the time of this writing, the technique has training centres in Montreal, the United States, and Europe, in addition to peer supervision groups. Based on multi-decade followup interviews, changes from Intensive Short-Term Dynamic Psychotherapy appear to be deep, multidimensional, and permanent. Patients are able to enjoy greater intimacy in relationships, reunification with and forgiveness of genetic figures, and resolution of symptoms. The technique has been found efficacious in somatization (4), chronic headache (5), and

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personality disorders (6). It is included in a recent Cochrane Systematic Review of brief psychodynamic therapies in common mental disorders (7). Sources of funding related to this topic/Conflicts of interest: None References

1. Davanloo, H. "Intensive Short-Term Dynamic Psychotherapy." In Kaplan, H. and Sadock, B. (eds), Comprehensive Textbook of Psychiatry, 8th ed, Vol 2, Chapter 30.9, 2628­2652. Philadelphia: Lippincot Williams & Wilkins, 2005. 2. Davanloo, H. Unlocking the unconscious: Selected papers of Habib Davanloo, MD. New York: Wiley, 1995, ISBN 978-0471956112. 3. Davanloo, H. Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. New York: Wiley, 2000, ISBN 9780471497042. 4. Abbass A, Kisely S, Kroenke K. Short-

term psychodynamic psychotherapy for somatic disorders. Systematic review and meta-analysis of clinical trials. Psychother Psychosom. 2009;78(5):265-74. 5. Abbass A, Lovas D, Purdy A. Direct diagnosis and management of emotional factors in chronic headache patients. Cephalalgia. 2008 Dec;28(12): 1305-14. 6. Abbass A, Sheldon A, Gyra J, Kalpin A. Intensive short-term dynamic psychotherapy for DSM-IV personality disorders: a randomized controlled trial. J Nerv Ment Dis. 2008 Mar;196(3):211-6. 7. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004687.

Allan Hirsh is a psychotherapist in North Bay. This cartoon is from his book Relax For the Fun of it: A Cartoon and Audio Guide to Releasing Stress. View at www. allanhirsh.com.

psychotherapist GP

Winter 2011

Visioning Exercise and Meeting

· By Edward Leyton MD, FCFP, CGPP Victoria Winterton MD, FCFP, MGPP

Howard Eisenberg MSc (Psych), MD Muriel J. van Lierop MBBS, MGPP Sunday February 27 2011 9:00 am - 5:00 pm OMA Offices 150 Bloor Street West, Toronto, Ontario

At the 2010 GPPA Conference we had a plenary session Envisioning a More Desirable Future for GP Psychotherapy which was facilitated by Howard Eisenberg. We began by participating in an `Ice-Breaking' process whereby we were introduced to new acquaintances for collaborating in the several Table Discussion Groups. Dr. Eisenberg then challenged us with two `seed questions'. Half of the groups brainstormed one question, and the other half brainstormed the other one: 1. What is limiting our personal sense of well being and professional satisfaction? 2. How to raise the profile of GP Psychotherapy with the Public and Government? We were then taught a Brainstorming mnemonic, SCAMPER, (based on the work of Alex Osborn and Bob Eberle), to catalyze `thinking-out-of-the-box': S - Substitute C - Combine A - Adapt M - Modify P ­ Put to other uses E - Eliminate R - Rearrange The groups worked well together. There was great enthusiasm and energy as the groups brainstormed. At the end, each group presented its ideas and suggestions to the whole conference. The suggestions that were given covered more than these two questions and can be summarized under the following headings:

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GPPA Visioning Meeting

1. Use of website and technology Explore ways to use technology to improve psychotherapy education for members and for the public. Some suggestions were an enewsleer, teleconferences and webcasts. 2. Working with other Health Care Professionals (including MDs) a. With patients b. To associate with them It was suggested that there could be more collaboration and beer communication across disciplines, including psychologists, social workers and other health care professionals, to provide beer care to patients. 3. Groups for members Groups could be set up for members with similar practices, or for those close geographically. 4. Different Therapy Ideas Explore different ways of doing therapy, for example, group therapy or long distance telephone therapy. 5. Connecting with Medical Students Reach out to medical students to raise awareness about psychotherapy. 6. Involvement in the schools and with companies Find ways to expand services to schools and companies. 7. Miscellaneous ideas Any member who would like to

see the full list of all the above ideas should contact Muriel van Lierop at 416-229-1993 to get it by fax, or [email protected] to receive it via e-mail. Trophic Model of Growth One concept for looking at this material in relation to the GPPA, is that the GPPA is in a metaphorical sense, a "living organism." Living organisms reach out for contact and connection, and they need to take in nutrients - in this case in the form of information, peer support, self-care, etc. For the organization to grow and mature from where it is now, it needs both of these components. This model simply represents a way of incorporating ideas that are generated in any brainstorming session, and puing them into categories that fit with our general philosophy of growth as an organization. That includes the growth of individual members as well as the organization itself. The arrows represent the "arms" of the organization with which we reach out to others - whether it is other individuals, political and patient groups, etc. There is personal outreach, and outreach to groups and organizations as opposed to individuals. The centre arrow represents how the organization takes in "food" - the nutrients - the nutrients could be in the form of self-care, peer support, conferences, and information from other organizations. The backdrop to all of this is the pyramid on

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GPPA Visioning (cont'd)

which the organization is based - our foundation and roots are strong, and we need to remember where we came from, and what we have built so far. From this model we can develop further ideas, and the ideas can be put into action in a variety of ways that are yet to be determined. The vitality of this organization is very much dependent upon the vitality of its members and the input that they have into the future of the GPPA. We want to move forward into the next decade with a vision for ourselves, for those we serve, and how we work together with other professionals. To this end we have organized a vision day. We invite and encourage you to aend. It is evident from the ideas generated in the session at the Annual Conference led by Dr. Eisenberg, that we need mutual support and connection, not just with each other, but also with other healthcare professionals in "the system." We have a valuable Basic Skills Course that more than meets the needs of those wishing to enter the field. People need to know about this! We are not using technology to its fullest extent, and ways of doing this need to be explored urgently. None of this can be accomplished unless we engage with each other so that we can continue to provide quality service, quality self-care, and still be on the leading-edge of medical psychotherapy. Please join us for this important day! Please see the registration form in the Newsleer ­ complete and fax or mail it to: GPPA Office, 312 Oakwood Court, Newmarket, ON L3Y 3C8 Tel: 416.410.6644 Fax: 1.866.328.7974

Tropic Model of Growth

OUTREACH AS A GROUP STRONG INTAKE FOUNDATION

PERSONAL OUTREACH

Visioning Meeting To Be Facilitated by Patricia Thompson Pai is an experienced facilitator, trainer, and consultant in the area of strategic planning, creative thinking, and leadership development. Pai has facilitated at association retreats for groups such as PMAC (Pharmaceutical Manufacturers of Canada) and CMA (Certified Managed Accountants). Pai is a graduate of Queen's University School of Business. She has personally trained under Dr. Edward de Bono and is one of a few worldwide master trainers in his thinking methodologies. She is also certified in Hermann Brain Dominance Instrument, MRG's LEA and SLP, Synectics, CPS, and is a CTI trained coach.

MARK YOUR CALENDAR GPPA Visioning Meeting Sunday February 27, 2011

OMA Office 150 Bloor St W, Suite 900 Toronto, Ontario Please see the registration form included with the Newsletter Fax or mail your RSVP to:

GPPA Office 312 Oakwood Court, Newmarket, ON L3Y 3C8 Fax: 1-866-328-7974

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psychotherapist GP

Winter 2011

Management of Obsessive Compulsive Disorder

· By Howard Schneider, MD, CGPP, CCFP

Sheppard Associates, 649 Sheppard Avenue, Toronto, Ontario, Canada M3H 2S4

Obsessive-Compulsive Disorder (OCD) has a lifetime prevalence of 2-3% of the general population in terms of meeting the full DSM-IV criteria. However, approximately one-quarter of the general population will have lessor amounts of obsessive and compulsive symptoms (Ruscio 2010). In considering all illnesses (both mental and physical), the WHO (World Health Organization) considers formal OCD to actually be the tenth leading cause of disability. The DSM-IV diagnosis of OCD requires either obsessions (recurrent thoughts which are inappropriate in relation to reallife issues and cause distress) or compulsions (repetitive behaviors which are aimed at reducing distress or preventing some dreaded situation, which again are inappropriate in relation to real-life issues), and requires the person to recognize, at some point anyway, that these obsessions or compulsions are unreasonable. To meet the DSM-IV diagnosis the obsessions or compulsions must cause marked distress, typically take more than an hour a day of the person's time or significantly interfere with the person's activities. There is much debate in the medical community as to the true nature of OCD. For example, Naomi Fineberg, speaking at the 2010 International Forum on Mood and Anxiety Disorders (IFMAD) and in publication (Stein, Fineberg 2010), questions whether OCD should even be considered an anxiety disorder. Ego-syntonic OCD without insight or even at delusional intensity complicates our definition of this disorder.

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Keep this in mind in providing care to the patient with OCD ­ you are dealing with an illness that may be far more complex and heterogeneous than the psychological conceptualizations of OCD or the current neuropsychiatric models we have for OCD. There are a number of useful OCD treatment guidelines ­ the 2005 U.K. NHS NICE (National Institute for Health and Clinical Excellence) OCD Guidelines, the 2006 Canadian Psychiatric Association OCD Guidelines and the 2007 American Psychiatric Guidelines (APA 2007). In a workshop given at the 2010 Canadian Psychiatric Association Annual Conference, Peggy Richter MD and Neil Rector PhD, in consideration of these guidelines and new findings in the years since their publication, presented a management strategy towards OCD (Richter and Rector 2010). This article describes Richter and Rector's management of OCD. In my own practice, before embarking upon treatment, I will have made a reasonable effort to rule out comorbidities. OCD is comorbid with many other psychiatric illnesses ­ full histories and a chance to get to know the patient are required. Work on the epidemiology of OCD (Rasmussen and Eisen 1990) found that some two-thirds of patients with OCD will suffer a Major Depressive Disorder during their life. Many times patients have been referred to me for OCD but it turns out there are other mental health issues that require current treatment. Doing a full set of labs (CBC, chemistry, thyroid, special chemistry as needed, ECG)

helps to rule out other comorbid medical illnesses, and as well is strongly recommended before psychopharmacology is provided. Cognitive Behavioral Therapy (CBT) is considered by Richter and Rector to be the first-line treatment for OCD. Behavioral techniques, particularly Exposure and Response Prevention (ERP), should first be tried. In the behavioral conceptualization of OCD, there is classical conditioning with a failure to extinguish of what should be normal thoughts or impulses with anxiety. The model hypothesizes that since the patient develops escape and avoidance behaviors (for example, washing one's hands) this prevents the normal extinction of the anxiety. A particular stimulus acts as an obsessional trigger, anxiety rises, and then the patient performs the compulsive ritual causing anxiety to decline. In ERP a goal of therapy is the prevention of compulsive rituals. In the example above, a patient with contamination fears, could, for example, take a piece of paper from the wastebasket in your office, and anxiety would result. The patient would be encouraged to resist, in this example, his/her usual hand-washing in response to the generated anxiety. Richter and Rector recommend that the patient have contact with an exposure for thirty minutes so that the patient can experience the habituation curve. With time and repeated exposures there is habituation to obsessional triggers. As a therapist you would establish a range of obsessional triggers for your patient, and set up a hierarchy of these triggers in terms of the

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Obsessive Compulsive Disorder (cont'd)

discomfort they cause. Therapy eventually progresses up the hierarchy of obsessional triggers. In my own practice, I use the workbook "Geing Over OCD" by Jonathan S. Abramowitz PhD (Abramowitz 2009) to help with both behavioral and cognitive therapy for my patients. Work at the Mayo Clinic (Abramowitz 2003) showed that for OCD with symptom subtypes of harming, contamination, unacceptable thoughts and symmetry, ERP Therapy produced significant symptom reduction. ERP for OCD with symptoms of hoarding was not as effective. How does this translate into the real world, into what we can expect in our practices? Richter and Rector note that while Exposure and Response Prevention Therapy is the "Gold Standard," about a quarter of patients will refuse this treatment option, a quarter of patients will show some partial response, and somewhere around a quarter of patients will show `pure' obsessions making this treatment modality less useful. Richter and Rector note that ERP delivers about 30% symptom reduction for about half the patients. For some patients this is enough symptom relief to greatly improve the quality of their lives, but obviously, for many other OCD patients, ERP will not provide adequate treatment. The `Cognitive Therapy' (CT) part of CBT should be considered for OCD. In the cognitive conceptualization of OCD, a neutral event is misinterpreted into a threatening, intrusive thought which raises anxiety, resulting in rituals to decrease the anxiety. To use an example given by Richter and Rector, while taking out the garbage the patient gets the intrusive thought or image: "This is filthy. I am going to make my kids sick." The patient appraises this obsession as that "everyone is going to see that I'm careless, that I'm a bad parent." Anxiety rises

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to 80%. (In CBT patients identify and score their emotions on a scale from 0 to 100%.) The patient then engages in an hour of handwashing, with the appraisal of the compulsion: "I must do everything not to spread germs." In Cognitive Therapy, there is psychoeducation about discomforting, intrusive thoughts that occur in everyone. Richter and Rector, as well, explain to patients that OCD is a chronic disease and establish realistic expectations from therapy. Cognitive restructuring, through the use of dysfunctional thought records, aempts to change the patient's faulty appraisals of his/her thoughts. Behavioral experiments can allow patients to test whether their beliefs are valid or not. Richter and Rector note that behavioral experiments in Cognitive Therapy are not formal exposure and response prevention. While this is true, like many therapists, in my practice I tend to combine both ERP and CT, and deliver full CBT to my patients with OCD. However it is justified to start with ERP. In comparing ERP and CT, Fisher and Wells 2005 show that ERP tends to be more effective than CT as treatment of obsessive-compulsive disorder where there is some symptom improvement. However, if a criterion of "asymptomatic" is used, Fisher and Wells note that both "ERP and cognitive therapy have low and equivalent recovery rates (approximately 25%)." Thus, even aer long periods of full CBT, many of our patients with OCD will still have debilitating symptoms. Richter and Rector suggest following the U.K. NICE OCD Clinical Guidelines (eg, Lovell, Bee 2008). These guidelines recommend CBT for OCD with mild functional impairment. For OCD with moderate functional impairment the guidelines recommend CBT or an SSRI, although Richter and Rector stress

that CBT should be the first-line treatment for mild to moderate OCD. If there is inadequate symptom improvement with either of these strategies, then the next step should be CBT plus an SSRI. Richter and Rector note that there are no studies yet comparing concomitant CBT plus SSRI or sequential CBT and then the addition of an SSRI. However, during CBT it is best to avoid changes in medications. (As well, benzodiazepine use should be avoided during CBT since these medications will defeat the effectiveness of the CBT techniques.) Simpson and colleagues 2008 show that serotonin reuptake inhibitors (SRIs) combined with CBT are more effective than SRIs alone, although in this study, patients were first treated with SRIs (as is oen the case in the real world since psychotherapy is not always available) and then one group received CBT and the control group received stress management training. Although CBT should always be considered as first-line treatment, Richter and Rector note that if there is comorbid Major Depression, severity of the OCD, lack of motivation, personality factors or lack of availability of psychotherapy, then medication (usually an SSRI) can be considered at the start of OCD treatment. However, CBT gives much lower relapse rates than medication alone and is very effective compared to medication alone. SSRIs should usually be the first choice of medication. Sertraline is a commonly used SSRI in OCD. The higher the dose used then the more patients with OCD symptoms who will achieve a response to the medication. Thus, in the treatment of OCD with sertraline, the target dose of 100

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Obsessive Compulsive Disorder (cont'd)

­ 200mg should be aempted. If the patient has a history of panic aacks or other comorbid anxiety disorders, then start low and go slow ­ these patients don't tolerate various physical side effects, even slight ones that the medication may produce. If sexual side effects occur, consider adding bupropion. Another strategy with regard to sexual side effects that can be successful, would be to miss a dose one day a week, and then have sex on the following day. An adequate trial of an SSRI means waiting 2-3 months at the maximal dosage. If there is inadequate response at that point, the clinical guidelines then suggest switching medication, although Richter and Rector advise increasing, for example, sertraline to at least 250300mg before switching. Some additional patients will respond at these higher doses. Work by Ninan and colleagues in 2006 at Emory University have found that sertraline doses up to 400mg/day produced the same safety profile as 200mg/day, but there was beer symptom improvement in the high-dose group. Although blood levels of SSRIs are not readily available, perhaps they should be. Speaking at IFMAD 2010, G. Zernig of the University of Innsbruck, Austria (Zernig 2010), noted that for all antidepressants investigated, despite patients all receiving the same dosage, their plasma levels varied up to 20-fold among different patients, and that it is the drug plasma level, not the dosage, that correlates best with clinical response. If the patient has responded adequately to the SSRI plus CBT, then the American Psychiatric Association (APA) Clinical Guidelines advise to continue the medication for 1 ­ 2 years and then gradually taper the medication over months, while providing periodic CBT booster sessions. If despite the high doses of

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sertraline (or other SSRI) and CBT, the patient has still not achieved adequate symptom relief, then following the APA Guidelines, if there has been some partial response to the SSRI + CBT, then augmentation with a second generation antipsychotic is recommended. If there has been lile response to the SSRI + CBT, then the guidelines recommend a number of possible strategies: - switch to a different SSRI - switch to clomipramine - augment with a secondgeneration antipsychotic - switch to venlafaxine - switch to mirtazapine Clomipramine blocks serotonin reuptake which makes it useful in OCD treatment. Clomipramine also blocks norepinephrine reuptake, which will result in increased dopamine in the prefrontal cortex (dopamine is inactivated by norepinephrine reuptake in the frontal cortex) which can be useful for some patients. In a metaanalysis of studies (Greist 1995) clomipramine gave beer efficacies than a number of SSRIs. However, clomipramine has anticholinergic side effects (eg, dry mouth), risk of arrhythmias, and a lowering of the seizure threshold. Richter and Rector note that at the 200mg/day maximum dose 4% of patients will experience seizures. Richter and Rector recommend venlafaxine, assuming blood pressure checks are fine, to 375mg, possibly 450mg per day. Duloxetine gives a similar response for OCD symptoms. Richter and Rector note antipsychotic augmentation with risperidone, olanzapine or quetiapine. There is the need to be careful of a metabolic syndrome. They note that aripiprazole anecdotally also seems to work in augmentation, but more studies are required. If there is associated anxiety, then

augmentation with clonazepam can be considered. If there is partial response to one of these strategies, then if not already done, augmentation with a second-generation antipsychotic should be tried. If in response to one of the above strategies there is still inadequate response, then the guidelines recommend a number of additional possible strategies: - switch to a different augmenting second-generation antipsychotic - switch to a different SRI - augment with clomipramine - augment with buspirone, pindolol, morphine, inositol, or a glutamate antagonist (riluzole, topiramate) Richter and Rector note that there is no evidence of benefit for lithium or valproate, unless there is a comorbid mood disorder. Gabapentin may have some value but a high dose is needed. Buspirone may ironically decrease the effectiveness of an SSRI it is added to. Beer evidence is noted for once per week PO morphine than IV morphine. A number of studies suggest the utility of high dose inositol in OCD. Topiramate in the 200mg or higher dose range works for OCD but there tends to be cognitive dulling. Memantine is also a possible glutamate modulating agent. If there was no or lile response, the guidelines recommend additional possible strategies: - switch to D-amphetamine monotherapy - switch to tramadol monotherapy - switch to ondansetron monotherapy - switch to an MAOI Richter and Rector did not discuss these additional possible strategies. However, speaking at

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Obsessive Compulsive Disorder (cont'd)

IFMAD 2010, Stefano Pallanti of Mount Sinai School of Medicine, New York (Pallanti 2010), noted that treatment resistance is very frequent in OCD and he discussed these and other more aggressive treatment strategies. Ondansetron is a serotonin 5HT3 receptor antagonist. Although used mainly as an antiemetic following chemotherapy, it has been found useful in OCD treatment. Pallanti notes that while risperidone augmentation acts on the anterior cingulate gyrus, ondansetron acts on the prefrontal cortex, as do amphetamines. Pallanti notes that ondansetron micro-augmentation of an SSRI and an antipsychotic can be useful for OCD treatment. Pallanti also notes that IV clomipramine seems to be much more effective than PO clomipramine, and can have a successful long-term efficacy in otherwise treatment refractory OCD. Richter and Rector then discuss alternatives for refractory OCD. Psychosurgery, particularly the capsulotomy, can give greater than 50% improvement rates. However, DBS ­ Deep Brain Stimulation ­ may represent a safer alternative to psychosurgery. There is currently more evidence for DBS use in refractory depression, but in a small study of treatmentrefractory OCD patients, outcomes were encouraging. rTMS (repetitive Transcranial Magnetic Stimulation) is non-invasive and has proven efficacious for Major Depression. However a number of studies of rTMS for OCD have given mixed results. Obsessive-Compulsive Disorder is a highly prevalent, chronic, disabling disorder. With appropriate treatment many patients can achieve enough symptom improvement to dramatically increase the quality of their lives. As medical psychotherapists we are in an ideal position to possess the

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knowledge and skills to treat this complex disorder with the counselling, psychoeducational, p s y c h o t h e r a p e u t i c , psychopharmacological and medical interventions that are required of the successful practitioner. Thanks to Dr. R. Tarzwell, FRCPC for helpful comments. References

Abramowitz JS, Geing Over OCD: A 10Step Workbook for Taking Back Your Life, The Guilford Press; Workbook edition (April 29, 2009) ISBN-13: 9781593859992. Abramowitz JS, Franklin ME, Schwartz SA, Furr JM, Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder, J Consult Clin Psychol. 2003 Dec;71(6):1049-57. American Psychiatric Association, Treatment of Patients With ObsessiveCompulsive Disorder, 2007, DOI: 10.1176/appi.books.9780890423363.1 49114. Fisher PL, Wells A, How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis, Behav Res Ther. 2005 Dec;43(12):1543-58. Greist JH, Jefferson JW, Kobak KA, JW Katzelnick DJ, Serlin RC, Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder - A meta-analysis, Arch Gen meta-analysis Psychiatry ,1995 Jan;52(1):53-60. Lovell K, Bee P, P Implementing the NICE OCD/BDD guidelines, Psychol Psychother. 2008 Dec;81(Pt 4):365-76. Epub 2008 Jun 28.

Ninan PT, Koran LM, Kiev A, Davidson PT JR, Rasmussen SA, Zajecka JM, Robinson DG, Crits-Christoph P, P Mandel FS, Austin C, High-dose sertraline strategy for nonresponders to acute treatment for obsessivecompulsive disorder: a multicenter double-blind trial, J Clin Psychiatry, 2006 Jan;67(1):15-22. Pallanti S, Augmentation strategies in resistant obsessive-compulsive disorders, International Journal of Psychiatry in Clinical Practice, Vol, 14, Supp. 1, November 2010. Rasmussen SA, Eisen JL, Epidemiology of obsessive compulsive disorder, J Clin Psychiatry, 1990 Feb;51 Suppl:10-3; discussion 14. Richter P and Rector N, Comprehensive Management of OCD, Canadian Psychiatric Association 2010 Annual Conference, September 26, 2010. Ruscio AM, Stein DJ, Chiu WT, Kessler WT RC, The epidemiology of obsessivecompulsive disorder in the National Comorbidity Survey Replication, Mol Psychiatry, 2010 Jan;15(1):53-63. Epub 2008 Aug 26. Simpson HB, Foa EB, Liebowitz MR, Ledley DR, Huppert JD, Cahill S, Vermes D, Schmidt AB, Hembree E, Franklin M, Campeas R, Hahn CG, Petkova E., A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsivedisorder, Am J Psychiatry, 2008 May;165(5):621-30. Epub 2008 Mar 3. Stein DJ, Fineberg NA, Bienvenu OJ, Denys D, Lochner C, Nestadt G, Leckman JF, Rauch SL, Phillips JF KA, Should OCD be classified as an anxiety disorder in DSM-V?, Depress Anxiety 2010 Jun;27(6):495-506. Zernig G, Therapeutic drug monitoring of antidepressants: controversies and possibilities, International Journal of Psychiatry in Clinical Practice, Vol, 14, Supp. 1, November 2010.

Beautiful Large office to rent in multi-disciplinary clinic in Leaside. Excellent opportunity for mutual referrals and to be part of a community of private practitioners. For more information, contact Annette Kussin at 416-440-2551 or [email protected] www.leasidetherapycentre.com

psychotherapist GP

Winter 2011

Book Review: The Impact of Early Life Trauma on Health and Disease - The Hidden Epidemic by Daniel Gilbert Edited by Ruth A.

Lanius, Eric Vermetten and Clare Pain

Hardcover, 302 pages, 2010 Cambridge University Press ISBN 978-0-521-88026-8 This book was first released on October 15, 2010 and, with the help of Muriel van Lierop, I was able to obtain a copy of it soon aerwards. I was very excited to get my hands on this volume because the theme of next year's GPPA conference is "Trauma and Aachment ­ Foundations for a Healing Paradigm" and both Ruth Lanius and Clare Pain are scheduled to present Keynote addresses at the conference. Ruth Lanius is an Associate Professor in Psychiatry and Director of the Traumatic Stress Service at the University of Western Ontario. Eric Vermeen is an Associate Professor in Psychiatry at the University Medical Center, Utrecht in the Netherlands. He has been trained both as a psychiatrist and a psychotherapist. He has lectured on the topic of PTSD in centres around the world. Clare Pain is an Associate Professor of Psychiatry at the University of Toronto and at the University of Western Ontario. She is the Clinical Director of the Psychological Trauma Assessment Clinic at Mount Sinai Hospital and she specializes in the assessment and treatment of patients with psychological trauma as well as the trans-cultural aspects of psychological trauma. These three editors bring a lifetime's worth of knowledge and experience to the topic of early life trauma and its effect on health and disease. The book presents a series of review articles on a wide variety of topics included under this subject heading. My initial survey of the book le me feeling overwhelmed. The pages of footnotes are oen longer than the articles themselves. Each paragraph of the text is very `meaty' and worthy of pause to

Winter 2011

· By Catherine Low, BSc (Med) MD, CGPP

views expressed by the authors of this paper. It helped me to realize how extremism of any kind can hinder rather than help to clarify complex issues such as these. The second part of the first section of the book is entitled `The Effects of Life Trauma: Mental and Physical Health'. The articles in this part examine the effects of trauma on infants right up to middle aged adults. One of the earlier chapters explores the concept that aachment dysregulation may be one of the `hidden traumas' in the life of an infant. In this situation the trauma does not come from a physical assault but from a maternal failure to regulate the infant's emotions in the face of fear provoking situations. Another chapter discusses the multitude of psychiatric diagnoses that trauma victims are oen classified under including: PTSD, depression, anxiety, ADD, addictions and personality disorders. The presence of multiple diagnoses oen makes a holistic approach to dealing with these patients virtually unobtainable. The authors propose a new diagnosis of Developmental Trauma Disorder to take into account the numerous effects that trauma has on patients in childhood and into adulthood. As I have said, every paragraph of this book is worthy of comment and reflection and this review cannot begin to describe the richness of this work. I have no doubt that it will become required reading for all health professionals who are dealing with traumatized clients. I am very grateful that my involvement in the planning of next year's conference has brought me in to contact with this valuable resource.

consider and digest. It was only aer reading the first several articles that I began to appreciate the work that the editors have put into making this a very valuable and very readable resource for anyone interested in the treatment of patients who have experienced complex trauma during childhood and adolescence. And from my experience, that description would fit the majority of the patients that I see on a day to day basis in my practice. The book is divided into three sections and each section is divided into two parts. The articles in each part build upon one another and the part is followed by a brief synopsis. This helps to make the book very easy to digest in small bites and also makes it easy to return to articles or parts of articles that you may wish to re-read later. As of the time of this review I have completed the first section of the book. This section is entitled `Early Life Trauma: Impact on Health and Disease'. The following two sections are entitled `Biological Approaches to Early Life Trauma' and `Clinical Perspectives: Assessment and Treatment of Trauma Spectrum Disorders'. The first section of the book is divided into two parts. The first part is `Childhood Trauma: Epidemiology and Historical Themes'. This part traces the history of the study of childhood trauma from the days of Freud until the present time. The articles outline how views of childhood trauma have been greatly influenced by the society in which we live. The concept of childhood trauma and abuse has been alternately embraced and rejected at different times in history. This part includes an article that discusses the `recovered memories' versus `false memories' controversy that arose in the 1980s. I appreciated the balanced

psychotherapist GP

11

Whom to Contact at the GPPA

Newsleer ­ to submit an article or comments, e-mail Howard Schneider at

[email protected]

2010/2011 GPPA Board of Directors

Muriel J. van Lierop, President, (416) 229-1993 [email protected] Julie Webb, Chair (416) 281-4884 [email protected] Jim Brown, Treasurer, (519) 856-0175 [email protected] Victoria Winterton, Past President, (519) 372-2511 [email protected] Jody Bowle-Evans, (705) 446-5013 [email protected] Derek Davidson, (416) 229-2399 [email protected] Howard Schneider, (416) 630-0610 [email protected]

Referral Line ­ to add your name or remove it from the online listing, contact the GPPA office To contact a member - look in the Membership Directory or contact the GPPA Office. Listserv ­ Clinical, Certificant and Mentor Members may e-mail Marc Gabel to join at [email protected] Questions about submiing educational credits ­ CE/CCI reporting ­ contact Helen Newman [email protected] or call 613-829-6360 Questions about the website CE/CCI system - for submiing CE/CCI credits, contact Muriel J. van Lierop at [email protected] or call 416-229-1993

REASONS FOR MEMBERS TO CONTACT THE GPPA OFFICE

Committees

Professional Development Commiee Catherine Carmichael, Chair Karyn Klapecki, Larry Nusbaum, Liaison to the Board ­ Derek Davidson Certificant Review Sub-Commiee Pam Mc Dermo, Victoria Winterton Mentor Review Sub-Commiee Joan Barr, Peggy Wilkins Education Commiee Will Irwin, Chair Jeanie Cohen, Elizabeth Parsons, Julie Webb Liaison to the Board ­ Julie Webb Membership Commiee Helen Newman, Chair Leslie Ainsworth, Mary Alexander, Norman Lauzon, Louis Morissee, Debbie Wilkes-Whitehall Liaison to the Board ­ Muriel J. van Lierop Finance Commiee Jim Brown, Chair Peggy Wilkins, Muriel J. van Lierop Liaison to the Board - Jim Brown Conference Commiee Cathherine Low, Chair Mary Alexander, Carol Hughes, Edward Leyton, Heidi Walk, Harry Zeit, Lauren Zeilig Liaison to the Board ­ Jody Bowle-Evans Listserv Marc Gabel, Webmaster Edward Leyton, Lauren Zeilig Liaison to the Board - Howard Schneider Newsleer Norman Steinhart Howard Schneider Liaison to the Board ­ Howard Schneider

1. 2. 3. 4. 5. 6.

To notify changes of address, telephone number, fax number and e-mail address. Add/Remove your name from the Online Referral Service To register for an educational event. To put an ad in the Newsleer. To request application forms in order to apply for Certificant or Mentor Status. To join the GPPA

GPPA Office, 312 Oakwood Court., NEWMARKET, ON L3Y 3C8 Contact person: Carol Ford Telephone (as before): 416-410-6644 Fax: 1-866-328-7974 E-mail: [email protected]

MARK YOUR CALENDAR GPPA Winter 2011 Educational Teleconference Series

Wednesday Evenings from 8:00 - 9:00 pm EDT via telephone conference call:

February 2 8-9 PM ­ Sex Therapy: Assessment of Sexual Dysfunction - Victoria Winterton February 23 8-9 PM ­ The Management of OCD ­ Howard Schneider March 30 8-9 PM ­ Trauma & Dissociation ­ Harry Zeit April 13 8-9 PM ­ Book Club: "When the Body Says No" by Gabor Mate - Jody Bowle-Evans & Julie Webb The capacity for each offering is 15 registrants. Teleconference dialin information will be sent to registrants 2 days prior to each session. You can claim 1 hour of CCI or CE credits for each teleconference. Cost: $20 per session, $60 for all sessions

Please register using the enclosed Teleconference Registration Form

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The views of individual Commiee and Board Members do not necessarily reflect the official position of the GPPA.

psychotherapist GP

Winter 2011

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