Psych - Psych Tx 3rd[2]

PSYCHIATRIC THERAPIES BASED ON FOUR MODELS OF PSYCHOPATHOLOGY Ma. Victoria Villanueva – Briguela, MD, FPPA

BIOLOGIC PSYCHO DYNAMIC

SOCIO BEHAVIOR CULTURAL

ETIO

Brain

Early P-Ch Relations

Social Relations

Learning

HX

S/S of Disease

Resolve Conflict & Strength Ego

Social D/O

Behavior

TX MOD

Rx, ECT

Psychotx

Reorg Social System

Modify Behavior

BIOLOGICAL MODEL 

I. Psychopharmacologic Agents : 1. Antipsychotics 2. Antidepressants 3. Antimanic 4. Anti anxiety

Antipsychotics a. Typical Agents – D2 receptor antagonism

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- older antipsychotics - Typicals divided into basis of POTENCY High Potency - 10mg or less Low Potency - 100mg more sedating and more anticholinergic side effects than High Potency

Biological - Antipsychotics - High Potency cause Acute Movement Abnormalities : Dystonia, Akathisia, Parkinson’s disease like Sx - depot injection medication reduces relapse rates by ½ to 1/3 w/ a consequent significant reduction in hospital bed occupancy.

Antipsychotics TYPICAL Low Potency doses 1. Chlorpromazine 500 to 1000

Side Effects Potential Prob sedation, Tardive Dyskinesia

Anticholinergic effects Seizures (Dry mouth, constipation urinary retention, blurred vision) Orthostatic Hypotension Extrapyramidal Sx, Sexual Dysfunction Typical High Potency 2. Haloperidol 5-20mg/d Extrapyramidal Symptoms Tardive Dysk (dystonias, Parkinson’s disease-like w/ long term use Sx, akathisia) 3. Fluphenazine Anticholinergic Sx NMS

Antipsychotics 2. Atypicals – Newer antipsychotics / 2nd generation Antipsychotics / Serotonin dopamine antagonists - fewer movement abnormalities, and decrease risk for TD - effective for those who were resistant to typical agents - effective for tx of positive and negative sx of schizophrenia

Biological Model - Antipsychotics 

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1. Clozapine – higher affinity for the D1 and D4 receptors than for D2.. Low incidence of EPS due to low activity at the D2 receptor. It also has antagonistic activity at 5HT1A, 5HT2A, 5HT2C and 5HT3 receptors. Also an antagonist at alpha1 and less at alpha2 result is sedation and hypotension. W/ antagonism of Histamine1 adds to the sedative effect and Weight gain is attributed to high affinity of clozapine for 5HT2C receptor.

Biological - Antipsychotics 

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- Clozapine is the most effective tx for pxs w/ schizophrenia refractory to other therapies and improves both positive and negative symptoms. Those treated w/ clozapine have greater reduction in side effects , disruptiveness, hospitalizations, and readmission after discharge

Antipsychotics - 2. Risperidone :

high affinity for 5HT2A receptor, w/ similar affinity to most typical antipsychotics at D2.  Increases serum prolactin;  w/ long acting depot formula -3, Olanzapine : its side effect profile is same as clozapine but w/ higher incidence of EPS at doses above 20mg/d. Has higher affinity to D2 and 5HT2A receptors than clozapine and lower affinity to D1. 

Antipsychotics 

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Olanzapine - effective for positive and secondary negative sx. It is also effective maintenance tx for schizophrenia; 4. Quetiapine – effective in acute phase studies; less EPS, cause more dizziness, dry mouth and sleepiness than risperidone 5. Amisulpride – the only one w/ effects on D2 and D3 receptors; has a projected optimum dose in the group of between 400 and 800mg/d ;

Antipsychotics -6. Ziprasidone :  high 5HT2A and D2 receptor blockade and high affinity for 5HT2A; also a partial agonist at 5HT1A receptor and potent affinity to D3, moderate affinity to D4 and exhibit weak serotonin and noradrenergic reuptake inhibition. .. Associated w/ greater than 30% decrease in depressive symptoms.  Linked to QT prolongation

Antipsychotics -7. Aripiprazole :  partial D2 agonist released in 2002 in USA, has high affinity for D2 receptors, and moderate affinity for the 5HT2A.  A partial agonist for 5HT1A  Produce a stabilizing effect on both the dopaminergic and serotonergic system .  - Has favorable safety and tolerability profile includes low potential for EPS, weight gain, prolactin elevation, QT prolongation and somnolence.

Antipsychotics 

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Rapid Neuroleptization : administering of hourly IM doses of dopamine receptor antagonist medication (e.g. haloperidol) till marked sedation is achieved. Maintenance : 1st episode 1-2yrs tx 2nd episode 5 years tx 3rd episode lifetime

Biological - Antidepressants  

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1. Tricyclic Antidepressants - older group, used less often than the newer drugs, . significant unpleasant side effects : sedation, anticholinergic effects ( dry mouth, constipation, urinary hesitancy, blurred vision) and orthostatic hypotension. The most serious effect is their cardiotoxicity with a quinidine-like effect of slowing cardiac conduction as an overdose. TCAs can be fatal.

Biological - Antidepressants 2. Monoamine Oxidase Inhibitors (MAOI) :used less often than the newer drugs  also cause unpleasant side effects like weight gain and anorgasmia  Absolute necessity for pxs on MAOI to maintain a tyramine-free diet to avoid a hypertensive crisis.  Foods contain tyramine like beer, wine, cheese , sausages – diet restriction is difficult.

Antidepressants 

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3. Selective Serotonin Reuptake Inhibitor (SSRI) : first agents used to tx depression; Specifically inhibit serotonin reuptake by presynaptic neurons Due to safety/ low risk overdose and well tolerated side effects ;

Antidepressants - SSRI     

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Indicated : Depression, Obsessive-Compulsive D/O (OCD), Panic D/O , Eating D/O Premenstrual Dysphoric D/O , Chronic Pain D/O, Paraphilias, and ADD / ADHD sexual side effects : decreased libido, delayed ejaculation and trouble reaching orgasm are common. It is not toxic; easy to use once a day dosing.

Antidepressants 

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depression begins to lift for most people after 2-4 weeks, longer at continual medication at therapeutic doses. Vegetative symptoms improve before mood symptoms do. Mirtazapine -(remeron) potent antagonist of H1 receptors and moderately potent antagonist of central presynaptic a1 adrenergic receptors. Half life 20 to 40 hrs

Antidepressants : 

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> Px with depression w/ psychotic symptoms ::: start w/ combination of an antipsychotic drug and an antidepressant. When psychotic symptoms have resolved the antipsychotic agent can be stopped and antidepressant can be continued for several more months…

Biological : Mood Stabilizers 

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In Bipolar disorder, the mainstay of pharmacotherapy : Lithium, valproate or carbamazepine, others (gabapentin, lamotrigine and topiramate). Antipsychotic agent is added when there are psychotic symptoms

Mood Stabilizers (Antimanic)  

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1. Lithium – 1st line treatment of bipolar I narrow therapeutic index; requires medical screening – check BUN and creatinine Lithium is excreted in kidneys; serum monitoring needed Therapeutic index 0.6-1.2mEq/L Initial side effects: nausea, vomiting, , polyuria and diarrhea

Mood Stabilizers 

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Valproic Acid : used for treatment of acute manic episode, 1st line tx of bipolar I ; Dose 20-30mg/kg BW Therapeutic Level 50-150ug/L Initial dose 250mg BID Side effect: alopecia, GI upset, sedation, weight gain Monitor liver function, CBC w/ platelets and serum amylase every 6 months

Mood Stabilizers  

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3. Carbamazepine : Approved for acute manic and mixed episodes of bipolar; Side effect: sedation, fatigue, dizziness, blurred vision, nausea Most common adverse event: nausea, vomiting, dizziness, sedation, benign rash Needs baseline assessment CBC w/ platelet

Mood Stabilizers 

Drug-Drug: Carbamazepine and Lamotrigine use concomitantly requires double dose of lamotrigine to achieve normal level; sudden stoppage of carba leads to increase level of lamotrig -> adverse event

Mood Stabilizers

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4. Lamotrigine – for maintenance tx of bipolar disorders w/ incidence of rash, more common in younger population

Biological - Anti Anxiety 

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* SSRIs, TCAs and MAOI are also effective antianxiety agents 1. SSRI – first line tx for panic d/o, social anxiety, OCD and PTSD 2. TCA – side effects are numerous, but used due to effect on insomnia or pain 3. MAOI – used for panic d/o and social phobia

Anti Anxiety 

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4. Benzodiazepene - high potency like alprazolam and clonazepam Alprazolam 1-8mg/d Clonazepam 1-4mg/d Lorazepam 2-12mg/day Initially tx w/ ssri is combined benzodzne for 1-2mos

ECT 

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Also called “Shock Therapy” involves a brief pulse of electricity to create a grand mal therapeutic seizure. The seizure treats the depression not the electricity Main contraindications are anesthetic like cardiac or pulmonary compromise

ECT      

Indications for ECT 1. Previous good outcome 2. Medication failure 3. Psychotic depression 4. Contraindications to medication 5. Severely suicidal

Psychodynamic        

Psychotherapy : 1. Hypnosis 2. Psychoanalytic a. Insight Oriented b. Exploratory c. Psychodynamic i. expressive ii supportive 3. Brief Psychotherapy

Psychodynamic  

4. Interpersonal Psychotherapy 5. Group Psychotherapy / Combined Group and Individual Psychotherapy and Psychodrama

Psychodynamic - Psychotherapy 

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Focuses on elucidating mental processes outside the px’s awareness leads to symptoms and promotes emotional and cognitive understanding An integration of elements of psychic conflicts Less strongly recommended, use if other tx are ineffective

Psychotherapy  

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Indications : 1. Px w/ significant suffering hence motivated to make sacrifice for time n financial resources 2. genuine wish to understand oneself 3. Can w/stand anxiety, frustration and strong affects that emerge in analysis w/o acting out in self-destructive manner 4. Mature superego and intelligence of at least average

Psychodynamic - Psychotherapy 

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1. Hypnosis – altered state of consciousness, a dissociated state and a state of regression; - it is a state when one can respond to appropriate suggestion by experiencing altered perceptions, memory or mood - use in Amnestic D/o, Dissociative Fugue

Psychodynamic - Psychotherapy 

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2. Psychoanalytic Psychotherapy – extended or long term, as long as 6mos a. Insight Oriented Psychotherapy b. Exploratory Psychotherapy c. Psychodynamic Psychotherapy i. Expressive ii. Supportive

Psychotherapy 

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Expressive – interpretation of unc conflicts to produce insight Supportive – giving advice and praise, focus on practical coping skills to assist px in daily living Analytic Setting – uses a couch, therapist sits behind, out of view of px’s vision Duration – 3-6yrs or more, >4x/week, 4550min/ session.

Psychodynamic     

Insight Oriented(Expressive) Supportive meaningful obj relation severely impaired good impulse control poor Reality testing intact poor Tolerate frustration poor tolerance

Psychotherapy   

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Analytic Process : transference, Countertransference, resistance 3. Psychodrama : a group psychotherapy, personality make-ups, interpersonal relationship conflicts and emotional problems are explored by means of special dramatic mtds. needs most participation and greatest ability to lead from therapist

Psychotherapy 

4. Family Therapy –focuses on altering the interactions among family members.

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5. Couples (Marital ) Therapy – modifies the interaction of 2 persons who are in conflict w/ each other over a parameter or a variety of parameters – emotional, sexual, financial

Behavior Therapy  

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1. Cognitive Behavioral THErapy (CBT) - highly recommended tx ; uses variety of approaches – psychoeducation, continuous monitoring, breathing retraining, cognitive restructuring, and in vivo exposure to fear cues . Goal = change assumptions, appraisals, perception, cognition/ ideas, beliefs  change in feelings &  change in bvr

Behavior Therapy 

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CBT – 3 components : didactic aspects, cognitive techniques and behavioral techniques - cognitive tech – elicit automatic thoughts (cognitive distortion), testing, identify maladaptive assumptions - behavioral tech – scheduling, mastery , graded task,, imagery

Behavioral 

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2. Biofeedback – relies on instrumentation to measure moment to moment feedback about physiological processes like measures of bp, temp, heart rate, etc Methods: instrumentation, relaxation, later adaptation of progressive muscle relaxation, autogenic training & applied tension

Behavior Therapy        

Other Techniques : 1. systematic desensitization 2. therapeutic graded exposure 3. flooding 4. participant modeling 5. exposure to stimuli in virtual reality 6. assertiveness training 7. aversive training

Behavior Therapy 

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1. Systematic Desensitization based on principle of counterconditioning ; A person overcomes anxiety elicited by a situation or an obj by approaching feared situation gradually in psychophysiological state that inhibits anxiety. > Steps used: relaxation, hierarchy construction and desensitization of stimulus

Behavior Therapy 

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> relaxation produced physiological effects opposite to those of anxiety – slows HR, neuromuscular stability > mental imagery pxs are instructed to imagine themselves in a place assoc’d w/ pleasant relaxed memories

Behavior Therapy 

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> hierarchy construction – list of items in order of increasing anxiety ex. Px imagines stand’g near a window of 2F and ends being on a roof of 20 story bldg > desensitization of stimulus –px proceed systematically using list fr the least to most anxiety provoking scenes while in deep relaxed state.

Behavior Therapy 

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2. Therapeutic Graded Exposure – like systematic desen., no relaxation training involved. 3. Flooding –(Implosion) like in Graded Exposure, involves exposing the px to feared object in vivo, has no hierarchy and no relaxation used.

Behavior Therapy 

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4. Participant Modeling – new behavior is learned by imitation primarily by observation w/o having to perform until they feel ready. 5. Assertiveness Training – confidence in judgment, sufficient self-esteem ; role modelling.

Behavior Therapy 

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6. Aversion Technique – a noxious stimulus is presented immediately after a specific behavioral response - electric shock , substance induced vomiting Positive Reinforcement – behavior response is followed by a generally rewarding event like food., praise.

Behavior Therapy   

- easily taught - less time than other therapies - less expensive to administer

Sociocultural 

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TX = Reorganizing patient’s relation to the social system i.e. restructure the nuclear social system thru marital/ couples & family Tx, environmental manipulation, Family intervention, Patient Education, Medication Compliance Therapy TX = Reorganizing social system e.g. advocacy for adequate housing & education, Assertive community Tx

Sociocultural 

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Family Intervention – reduces level of negative expressed emotion – anger, guilt, sad Patient Education – px engage in beh change, prevents hosp, manage illness n get maximum degree of health Medication Compliance Therapy – for px that stop meds

SOCIOCULTURAL MODEL       

TX Couple/ Marital, Family Tx Milieu Tx- Provide substitute or transitional social support ; 24-hr day prog in community Social Skills Trng- Acquire social skills to maintain relationships; role play Environmental Manipulation = Move residence to be nearer family & friends Vocational Trng -Encourage returning to work; Self- Help Programs

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Group Psycho – immediate feedback fr peers; chance to observe px’s responses to others Self-help Grp – pxs coping w/ specific prob organized and educate each other; cohesion.

BIOPSYCHOSOCIAL MODEL    

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MULTIMODAL TX ECT, Rx Psychotx Environmental Manipulation, Social Support Behavioral & / or Cognitive Tx

BIOLOGICAL

PSYCHODYNAMIC

SOCIOCULTURAL

BEHAVIORAL

ETIO Brain

Early P-Ch Relations

Social Relations

Learning

HX

S/S of Disease

Resolving Conflict & Strengthen Ego

Social Disorder

Behavior

TX

Rx

PsychotX

Reorg Social System

Modify Behavior

Thank you

QUIZ:Give Model of Psychopathology where the Psychiatric Treatment Belong.    

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Biological, Behavioral, Psychodynamic, Sociocultural 1. Systematic desensitization 2. Clozapine 3. Environmental manipulation is a treatment mode used by patient. 4. Quetiapine 5. ECT 6 Biofeedback 7. Family Intervention 8. Psychoanalytic PSychotherapy 9. Patient Education 10. Role modeling for phobic children.