Tag Archives: Cognitive Behavioral Therapy

Trichotillomania


The diagnosis of Trichotillomania (TM) is synonymous with the act of recurrently pulling one’s own body hair resulting in noticeable thinning or baldness.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 674)  Sites of hair pulling can include any area of the body in which hair is found, but the most common sites are the scalp, eyelashes, eyebrows, and the pubis area.  (Kraemer, 1999, p. 298)  The disorder itself is categorized in the DSM-IV-TR as an “Impulse Control Disorder Not Elsewhere Classified” along with disorders like Pathological Gambling, Pyromania, Kleptomania, and Intermittent Explosive Disorder.  Although TM was previously considered to be a rare disorder, more recent research indicates that prevalence rates of TM may be as high as 2% of the general population.  (Kraemer, 1999, p. 298)  This prevalence rate is significantly higher than the lifetime prevalence rate of .6% that is cited as a potential baseline among college students the DSM-IV-TR.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  The condition appears to be more common among women and the period of onset is typically in childhood or adolescence. (Kraemer, 1999, p. 298)  As is customary with most DSM-IV-TR diagnoses, the act of hair pulling cannot be better accounted for by another mental disorder (like delusions, for example) or a general medical condition.  Like every disorder in the DSM-IV-TR, the disturbance must cause significant distress or impairment in functioning.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 675)

Alopecia is a key concept that must be understood in order to complete the differential diagnosis of TM.  Alopecia is a condition of baldness in the most general sense.  (Shiel, Jr. & Stoppler, 2008, p. 14)  Other medically related causes of alopecia should be considered in the differential diagnosis of TM, especially when working with an individual who deny pulling their hair.  The common suspects include male-pattern baldness, Discoid Lupus Erythematosus (DLE), Lichen Planopilaris (also known as Acuminatus), Folliculitis Decalvans, Pseudopelade of Brocq, and Alopecia Mucinosa (Follicular Mucinosis).  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  Comprehensive coverage of these medical conditions is beyond the scope of this article – all of the aforementioned confounding variables can be eliminated by a general practitioner.

There are a number of idiosyncratic features associated with TM that bear mentioning.  Although the constellation of features covered here is not sufficient to warrant a diagnosis in isolation, they can aid in the differential diagnosis process.  Alopecia, regardless of the cause, has been known to lead sufferers to tremendous feats of avoidance so that the hair loss remains undetected.  Simply avoiding social functions or other events where the individual (and their attendant hair loss) might be uncovered is a common occurrence.  In cases where individual’s focus of attention is on the head or scalp, it is not uncommon for affected individuals to attempt to hide hair loss by adopting complimentary hair styles or wearing other headwear (e.g., hats, wigs, etc).  These avoidance behaviors will be the target of exposure and response prevention later in this article.

In addition to avoidant behavior and elaborate attempts to “cover it up,” individuals with TM frequently present with clinically significant difficulty in areas such as self-esteem and mood.  Comorbidity, or the presence of one or more disorders in the addition to a primary diagnosis, is the rule not the exception in the stereotypical presentation of TM.  Mood disorders (like depression) are the most common (65%) – anxiety (57%), chemical use (22%), and eating disorders (20%) round out the top four mostly likely candidates for comorbidity.  (Kraemer, 1999, p. 298)  These comorbidity rates are not overly surprising since they parallel prevalence rates across the wider population – perhaps with the notable exception of the high rate of comorbid eating disorders.  We can speculate about the source of comorbidity – one possible hypothesis is that a few people who suffer TM also suffer from a persistent cognitive dissonance associated with having happy-go-lucky personality trait which leads them “let the chips fall where they may.”  They are individuals prone to impulsivity, but they are subdued and controlled the shame, guilt, frustration, fear, rage, and helplessness associated with the social limitations placed on them by the disorder.  (Ingram, 2012, p. 269)  On the topic of personality, surprisingly enough, research suggests that personality disorders do not share significant overlap with TM.  This includes Borderline Personality Disorder (BPD) despite the fact that BPD is often associated with self-harming behavior.  (Kraemer, 1999, p. 299)

Differentiating TM from Obsessive-Compulsive Disorder (OCD) can be challenging in some cases.  TM is similar to OCD because there is a “sense of gratification” or “relief” when pulling the hair out.  Unlike individuals with OCD, individuals with TM do not perform their compulsions in direct response to an obsession and/or according to rules that must be rigidly adhered to.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 676)  There are, however, observed similarities between OCD and TM regarding phenomenology, neurological test performance, response to SSRI’s, and contributing elements of familial and/or genetic factors.  (Kraemer, 1999, p. 299)  Due to the large genetic component contributions of both disorders, obtaining a family history (vis-à-vis a detailed genogram) is highly recommended.  The comprehensive genogram covering all mental illness can be helpful in the discovery the comorbid conditions identified above as well.

There is some suggestion that knowledge of events associated with onset is “intriguing, but unnecessary for successful treatment.”  (Kraemer, 1999, p. 299)  I call shenanigans.  There is a significant connection between the onset of TM and the patient enduring loss, perceived loss, and/or trauma.  Time is well spent exploring the specific environmental stressors that precipitated the disorder.  Although ignoring circumstances surrounding onset might be prudent when employing strict behavioral treatment paradigms, it seems like a terrible waste of time to endure suffering without identifying some underlying meaning or purpose that would otherwise be missed if we overlook onset specifics.  “Everything can be taken from a man but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”  (Frankl, 1997, p. 86)  If we acknowledge that all behavior is purposeful, then we must know and understand the circumstances around onset if we will ever understand the purpose of said behavior.  I liken this to a difference in professional opinion and personal preference because either position can be reasonably justified, but in the end the patient should make the ultimate decision about whether or not to explore onset contributions vis-à-vis “imagery dialogue” or a similar technique.  (Young, Klosko, & Weishaar, 2003, p. 123)  If such imagery techniques are unsuccessful or undesired by the client, a psychodynamic conversation between “internal parts of oneself” can add clarity to the persistent inability of the client to delay gratification.  (Ingram, 2012, p. 292)  Such explorations are likely to be time consuming, comparatively speaking, and should not be explored with patients who are bound by strict EAP requirements or managed care restrictions on the type and length of treatment.  Comorbid developmental disabilities and cognitive deficits may preclude this existential exploration.  I employ the exploration of existential issues of origin in the interest of increasing treatment motivation, promoting adherence, enhancing the therapeutic milieu, and thwarting subsequent lapses by anchoring cognitive dissonance to a concrete event.

TM represents a behavioral manifestation of a fixed action patterns (FAPs) that is rigid, consistent, and predicable.  FAPs are generally thought to have evolved from our most primal instincts as animals – they are believed to contain fundamental behavioral ‘switches’ that enhance the survivability of the human species.    (Lambert & Kinsley, 2011, p. 232)  The nature of FAPs that leads some researchers to draw parallels to TM is that FAPs appear to be qualitatively “ballistic.”  It’s an “all or nothing” reaction that is comparable to an action potential traveling down the axon of a neuron.  Once they are triggered they are very difficult to suppress and may have a tendency to “kindle” other effects.  (Lambert & Kinsley, 2011, p. 233)

There are some unique considerations when it comes to assessing a new patient with TM.  Because chewing on or ingesting the hair is reported in nearly half of TM cases, the attending clinician should always inquire about oral manipulation and associated gastrointestinal pain associated with a connected hair mass in the stomach or bowel (trichobezoar).  Motivation for change should be assessed and measured because behavioral interventions inherently require a great deal of effort.  Family and social systems should not be ignored since family dynamics can exacerbate symptomatlogy vis-à-vis pressure to change (negative reinforcement), excessive attention (positive reinforcement), or both.  (Kraemer, 1999, p. 299)

What remains to be seen is the role of stress in the process of “triggering” a TM episode.  Some individuals experience an “itch like” sensation as a physical antecedent that remits once the hair is pulled.  This “itch like” sensation is far from universal.  Some clinicians and researchers believe that the abnormal grooming behavior found in TM is “elicited in response to stress” with the necessary but not sufficient condition of “limited options for motoric behavior and tension release.”  (Kraemer, 1999, p. 299)  Although this stress hypothesis may materialize as a tenable hypothesis in some cases, it’s by no means typical.  Most people diagnosed with TM report that the act of pulling typically occurs during affective states of relaxation and distraction.  Most individuals whom suffer from TM do not report clinically significant levels of anxiety as the “trigger” of bouts of hair pulling.  We could attribute this to an absence of insight regarding anxiety related triggers or, perhaps anxiety simply does not play a significant role in the onset and maintenance of hair pulling episodes.  Regardless of the factors that trigger episodes, a comprehensive biopsychosocial assessment that includes environmental stressors (past, present and anticipated) should be explored.

The options for treatment of TM are limited at best.  SSRIs have demonstrated some potential in the treatment of TM, but more research is needed before we can consider SSRIs as a legitimate first-line treatment.  SSRIs are worth a shot as an adjunct treatment in cases of chronic, refractory, or treatment resistant TM.  I would consider recommending a referral to a psychiatrist (not a general practitioner) for a medication review due in part to the favorable risk profile of the most recent round of SSRIs.  Given the high rate of comorbidity with mood and anxiety disorders – if either is anxiety or depression are comorbid, SSRIs will likely be recommended regardless.  Killing two birds with one stone is the order of the day, but be mindful that some medication can interfere with certain treatment techniques like imaginal or in vivo exposure.  (Ledley, Marx, & Heimberg, 2010, p. 141)  Additional research is needed before anxiolytic medications can be recommended in the absence of comorbid anxiety disorders (especially with children).  Hypnosis and hypnotic suggestion in combination with other behavioral interventions may be helpful for some individuals, but I don’t know enough about it at this time to recommend it.  Call me skeptical, or ignorant, but I prefer to save the parlor tricks for the circus…

Habit reversal is no parlor trick.  My goal isn’t to heal the patient; that would create a level of dependence I am not comfortable with… my goal is to teach clients how to heal themselves.  Okay, but how?  The combination of Competing Response Training, Awareness/Mindfulness Training, Relaxation Training, Contingency Management, Cognitive Restructuring, and Generalization Training is the best hope for someone who seeks some relief from TM.  Collectively I will refer to this collection of techniques as Habit Reversal.

Competing Response Training is employed in direct response to hair pulling or in situations where hair pulling might be likely.  In the absence of “internal restraints to impulsive behavior,” artificial circumstances are created by identifying substitute behaviors that are totally incompatible with pulling hair.  (Ingram, 2012, p. 292)  Just like a compulsive gambling addict isn’t in any danger if spends all his money on rent, someone with TM is much less likely to pull hair if they are doing something else with their hands.

Antecedents, or triggers, are sometimes referred to as discriminative stimuli.  (Ingram, 2012, p. 230)  “We sense objects in a certain way because of our application of priori intuitions…”  (Pirsig, 1999, p. 133)  Altering the underlying assumptions entrenched in maladaptive priori intuitions is the core purpose of Awareness and Mindfulness Training.  “There is a lack of constructive self-talk mediating between the trigger event and the behavior. The therapist helps the client build intervening self-messages: Slow down and think it over; think about the consequences.”  (Ingram, 2012, p. 221)  The connection to contingency management should be self evident.  Utilizing a customized self-monitoring record, the patient begins to acquire the necessary insight to “spot” maladaptive self talk.  “Spotting” is not a new or novel concept – it is central component of Abraham Low’s revolutionary self help system Recovery International.  (Abraham Low Self-Help Systems, n.d.)  The customized self-monitoring record should invariably include various data elements such as precursors, length of episode, number of hairs pulled, and a subjective unit of distress representing the level of “urge” or desire to pull hair.  (Kraemer, 1999)  The act of recording behavior (even in the absence of other techniques) is likely to produce significant reductions in TM symptomatlogy.  (Persons, 2008, p. 182-201)  Perhaps more importantly, associated activities, thoughts, and emotions that may be contributing to the urge to pull should be codified.  (Kraemer, 1999, p. 300)  In session, this record can be reviewed and subsequently tied to “high risk circumstances” and “priori intuitions” involving constructs such as anger, frustration, depression, and boredom.

Relaxation training is a critical component if we subscribe to the “kindling” hypothesis explained previously.  Relaxation is intended to reduce the urges that inevitably trigger the habit.  Examples abound, but diaphragmatic breathing, progressive relaxation, and visualization are all techniques that can be employed in isolation or in conjunction with each other.

Contingency Management is inexorably tied to the existential anchor of cognitive dissonance described above.  My emphasis on this element is where my approach might differ from some other clinicians.  “You are free to do whatever you want, but you are responsible for the consequences of everything that you do.”  (Ingram, 2012, p. 270)  This might include the client writing down sources of embarrassment, advantages of controlling the symptomatlogy of TM, etc.  (Kraemer, 1999)  The moment someone with pyromania decides that no fire worth being imprisoned, they will stop starting fires.  The same holds true with someone who acknowledges the consequences of pulling their hair.

How do we define success?  Once habit reversal is successfully accomplished in one setting or situation, the client needs to be taught how to generalize that skill to other contexts.  A hierarchical ranking of anxiety provoking situations can be helpful in this process since self-paced graduated exposure is likely to increase tolerability for the anxious client.  (Ingram, 2012, p. 240)  If skills are acquired, and generalization occurs, we can reasonably expect a significant reduction in TM symptomatlogy.  The challenges are significant, cognitive behavioral therapy is much easier said than done.  High levels of treatment motivation are required for the behavioral elements, and moderate to high levels of insight are exceptionally helpful for the cognitive elements.  In addition, this is an impulse control disorder… impulsivity leads to treatment noncompliance and termination.  The combination of all the above, in addition to the fact that TM is generally acknowledged as one of the more persistent and difficult to treat disorders, prevents me from providing any prognosis other than “this treatment will work as well as the client allows it to work.”

References

Abraham Low Self-Help Systems. (n.d.). Recovery international terms and definitions. Retrieved August 2, 2012, from http://www.lowselfhelpsystems.org/system/recovery-international-language.asp

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Frankl, V. E. (1997). Man’s search for meaning (rev. ed.). New York, NY: Pocket Books.

Ingram, B. L. (2012). Clinical case formulations: Matching the integrative treatment plan to the client (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Kraemer, P. A. (1999). The application of habit reversal in treating trichotillomania. Psychotherapy: Theory, Research, Practice, Training, 36(3), 298-304. doi: 10.1037/h0092314

Lambert, K. G., & Kinsley, C. H. (2011). Clinical neuroscience: Psychopathology and the brain (2nd ed.). New York: Oxford University Press.

Ledley, D. R., Marx, B. P., & Heimberg, R. G. (2010). Making cognitive-behavioral therapy work: Clinical process for new practitioners (2nd ed.). New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.

Pirsig, R. M. (1999). Zen and the art of motorcycle maintenance: An inquiry into values (25th Anniversary ed.). New York: Quill.

Shiel, W. C., Jr., & Stoppler, M. C. (Eds.). (2008). Webster’s new world medical dictionary (3rd ed.). Hoboken, NJ: Wiley Publishing.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. New York: Guilford Press.

Theory and Practice of Existential Group Psychotherapy


Abstract

 

A general description of existential theory and process is provided with specific attention given to the interpersonal dynamics of group facilitation.  Aspects that differentiate this approach from practice guided by Applied Behavior Analysis are presented along with a detailed analysis of the specific group demographics that can be well served by this approach.  Finally, a case example is provided as a concrete example of the application of existential thought to the group environment.

**ALL REFERENCES TO ANY INDIVIDUAL OR PERSONS ARE PURELY COINCIDENTAL

 

 

Theory and Practice of Existential Group Psychotherapy

Death – Freedom – Isolation – Meaninglessness… these words can’t conveniently package a product like existential psychotherapy.  “Existentialism is a philosophy that addresses what it means to be human.”  (Gladding, 2008, p. 352)  We would be hard pressed to find “heavier” content to try to assemble and process against the backdrop of group theory and process.  I choose to start with one word.  Why?  That simple word serves as the underlying premise on which a rewarding existential dialogue can be constructed in a group setting, and the foundation on which this essay is constructed.

Why draw attention to death and death anxiety?  Human beings are unique because they strive to persist in the physical world, yet they are aware of the inevitably of death for the majority of their natural lives.  The terror of death is ever-present and of such enormity that a considerable portion of one’s “oomph” is consumed in the practice of denying death.  (Yalom, 1980, p. 41)  How can we combat death anxiety in the group therapy environment?  “A person cannot bear to face the prospect of inevitable death unless he has had the experience of fully living.”  (Yalom, 1980, p. 208)  Existential group psychotherapy aims to provide that experience.

Patients, given the slightest encouragement, will bring in an extraordinary amount of material related to a concern about death.  They discuss the deaths of parents or friends, they worry about growing old, their dreams are haunted by death, they go to class reunions and are shocked by how much everyone else has aged, they notice with an ache the ascendancy of their children, they occasionally take note, with a start, that they enjoy old people’s sedentary pleasures.  They are aware of many small deaths: senile plaques, liver spots on their skin, gray hairs, stiff joints, stooped posture, and deepening wrinkles.  (Yalom, 1980, p. 57)

Why freedom?  Why responsibility?  “As long as patients persist in believing that their major problems are a result of something outside their control- the actions of other people, bad nerves, social class injustices, genes- then we therapists are limited in what we can offer.”  (Yalom, 1995, p. 139)  Although we almost universally attribute a positive connotation to the word “freedom,” existential psychotherapists recognize and emphasize that freedom comes with a tremendous responsibility.  The burden of structuring our individual lives, and taking responsibility for all our choices- past, present, and future- is not a trivial event.  “One is wholly responsible for one’s life, not only for one’s actions but for one’s failures to act.”  (Yalom, 1980, p. 220)  We yearn for autonomy, but we recoil from its inevitable consequences.  Acknowledgement that we are free to choose comes with an embedded acknowledgment that if we have the power to change our circumstances in the present, we also had the ability to make those same changes in the past.  Where did all that time go?  Existential guilt is created because we come to realize that we have consciously chosen not to free ourselves, to keep ourselves in bondage.  We come to the realization that despite our wish for the future to be different, we must mount sufficient will to traverse the chaotic ocean of uncertainty.

A client drove this concept recent.  This particular client suffered from a traumatic brain injury as a young child.  She was diagnosed with a pervasive developmental disability due to the injury and committed to take up residence in a group home setting for people with developmental disabilities.  It would suffice to say that this individual was very angry with the situation and had an exceptionally difficult time dealing with her persistent desire to live independently.  Although the supporting staff had clearly designated the goal as “a free and autonomous life without need for support” it was clear that the individual served didn’t feel that way.  The individual coveted the luxuries independence, but there was an underlying existential concern that stood opposed to that goal… “if I recover, I will no longer get the support she have become accustomed to.”  The checks from the state will stop.  No more safety-net.  If she fails- she fails and suffers the consequences of failure like everyone else – and that was a scary concept.  Despite repeated encouragement that she was “high functioning enough” to live independently, and reassurances that the agency wasn’t just going to “shove her out the door,” that underlying fear of freedom led to repeated incidents of aggressive behavior that served to insure that the individual would never been removed from the support of the state or the agency entrusted with her care.  The individual “cursed the safety net” while simultaneous embracing it.  She demanded more autonomy and fewer restrictions, yet refused move in that direction for fear that she might appear to be “too competent.”  Real freedom means she had the freedom to fail- and that was unacceptable.  I submit that this cycle of learned helplessness occurs more often than we are willing to admit, especially in the context of supporting individuals with developmental disabilities.

 

Why existential isolation?  There are three types of isolation: interpersonal, intrapersonal, and existential.  Interpersonal isolation is typically experienced as loneliness, and generally refers to the isolation from other individuals.  (Yalom, 1980, p. 353)  Conversely, intrapersonal isolation takes place when we stifle our feelings and subsequently accept “oughts” or “shoulds” (borrowed from Rational Emotive Behavior Therapy and Dr. Albert Ellis) as our own wishes.  (Yalom, 1980, p. 354)  Existential isolation refers to the most fundamental isolation – isolation both from creatures and from the world.  It is the “unbridgeable gulf between oneself and any other being” or thing.  (Yalom, 1980, p. 355)  Our wish to be part of a larger whole hangs in the balance.  No one captures the spirit of existential isolation like Yalom (1980) when he wrote:

We are all lonely ships on a dark sea.  We see the lights of other ships- ships that we cannot reach but whose presence and similar situation affords us much solace.  We are aware of our utter loneliness and helplessness.  But if we can break out of our windowless monad, we become aware of the others who face the same lonely dread.  Our sense of isolation gives way to a compassion for the others, and we are no longer quite so frightened.  (p. 398)

I am wholly in agreement with Yalom (1980) that the best way to combat isolation in all its forms, at least within the context of group therapy, is to foster genuine relationships.  “This requires the therapist to approach the patient without presuppositions, to focus on the project of sharing the patient’s experiences without rushing in to judge or stereotype the patient.”  (Yalom, 1980, p. 409)  In the selfless act of genuine caring the therapist emits “non-conditional” love that transcends “rebelliousness, narcissism, depression, hostility, and mendacity.  In fact, one might say that the therapist cares because of these traits, since they reflect how much the individual needs to be cared for.”  (Yalom, 1980, p. 408)  This concept translates easily into the group therapy environment.  It has been said that “a freely interactive group, with few structural restrictions, will, in time, develop into a social microcosm of the participant members.”  (Yalom, 1995, p. 28)  If an individual group member chooses to stub out anything that resembles an interpersonal supporting structure in their real lives, it should come out in the group.  It is the responsibility of the existential group leader to embolden members to accept personal responsibility for the choices that have led to interpersonal isolation – to provide tools to evade mechanisms of intrapersonal isolation – and to underscore the importance of a “here-and-now focus” through “process illumination.”  (Yalom, 1995, p. 139)

 

Why do we live?  How shall we live?  Making meaning matter.  The existential dynamic conflict of meaninglessness is fueled by meaning seeking human beings who are inescapably thrown into a universe that is devoid of meaning.  Some of the world’s finest minds have approached it from various positions in effort to reveal its raw materials.  Among them, Jung suggests that meaning is merely the recognition of patterns of order.  (Storr, 1983, p. 26)  Gabriel Marcel sits in communion – a valiant effort to protect his subjectivity from annihilation at the hands of materialism.  Jean-Paul Sartre is nauseated by the transcendent cup of consciousness he called – “other.”  Nietzsche’s dead gods yearn for their will to power.  Søren Kierkegaard leaps into a subjective faith while Dostoevsky enlists spiritual values in a timeless war against the hands of evil.  Kafka’s pen drips with characters discovering the depths of alienation and persecution.  Yalom stares at the sun.

 

What we must do is plunge into one of the many possible meanings, particularly one with a self transcendent basis.  It is engagement that counts, and we therapists do most good by identifying and helping to remove the obstacles to engagement.  The question of life is, as the Buddha taught, not edifying.  One must immerse oneself into the river of life and let the question drift away.  (Yalom, 2002, p. 135-136)

 

What populations do existential groups NOT work for?  Existential groups come with some limitations that are inherent in the underlying philosophy, and other limitations that are specific to individual participants in the group.  First among them is a concern that existential groups only benefit members who are verbal, communicative, and unafraid to confront painful issues.  (Gladding, 2008, p. 357)  Tackling concepts like death and the meaning of life aren’t for the faint of heart.  Because of the primacy and intimacy of the content, use is primarily confined to counseling and psychotherapy settings.  Existential concerns are wholly inappropriate for most psycho-educational, task, or work groups.  The approach takes considerable amounts of maturity, life experience, and close supervision and is not recommended which presents a significant obstacle for developing group leaders.  Finally, existentialism and existential groups are characterized as being broadly based because they generally don’t deal with specific behaviors or concerns.  As a result, “group members who need information or immediate answers are not good candidates for these groups.”  (Gladding, 2008, p. 358)

 

“It’s complicated.”  Let us, if we can, bring this conversation back down to earth and use a concrete example – a group activity focused on defining our relationship with our significant other.  It’s complicated is an existential group activity that forces participants to qualitatively explain and justify the relationship status that they pick on Facebook.  It’s based on a very fundamental concept – the relationships we keep are chosen by us, not for us.  The options are many – single, engaged, married, widowed, separated, or divorced.  Perhaps it’s just a relationship, open or otherwise, that defies all of the above.  It could be labeled a civil union, or a domestic partnership.  Last, but certainly not least, there is the most popular choice… “It’s complicated.”  Existential group psychotherapy was tailor-made for “it’s complicated.”  The beauty of the search is that the journey is as important as the destination, and the process of getting there is much more enriching than actually arriving (if that is even possible).

What differentiates existential psychotherapy from other theories?  Yalom defines existential psychotherapy as “a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence.”  (Yalom, 1980, p. 5)  Like its Freudian psychodynamic predecessor, existential psychotherapy moves under the tacit assumption that there are “forces” that exist at assorted levels of awareness.  It’s a precious gift of insight surrounded by layer upon layer of repression, denial, displacement, and symbolization.  It’s learning to make choices under the eternal auspice of the future becoming the present.  It’s a royal road that can be traversed in “deep reflection, dreams, nightmares, flashes of profound experience and insight, psychotic utterances, and the study of children.”  (Yalom, 1980, p. 6) 

Comparatively speaking, behavioral psychotherapists rely primarily on what and when questions that focus on the environmental conditions that exist before, during, and after a behavioral episode.  They would much prefer to avoid the question of why.  The question why tends to evoke “mentalistic explanations that are of little value” to a behaviorist who is attempting to understand the behavior of interest.  An existential line of questioning that demands an inquiry into the reason why could be viewed as encouraging “motivational” reasons that are “usually uninformative” to a behaviorist.  (Cooper, Heron, & Heward, 2007, p. 50)  Generally speaking no existential psychotherapist is going to avoid or evade questions about what and when, but I wonder if I am the only one who sees some irony in the dichotomy.  Surely if you ask a behaviorist why someone behaves the way they do they would provide you with an answer, yet they evade motivational questions to which they have no behavioral solutions.  A stalwart behaviorist doesn’t care why because he thinks he knows why.

“A real change occurring in the absence of action (behavior) is a practical and theoretical impossibility.”  (Yalom, 1980, p. 287)  Behaviorists prefer to define behaviors functionally.  “Functional definitions are often simpler and more concise than topographical definitions, leading to easier, more accurate, and more reliable measurement.  (Cooper et al., 2007, p. 66)  Herein lays the problem – “The precision of the result is directly proportional to the triviality of the variable studied.”  (Yalom, 1980, p. 24)  I challenge any behavior oriented therapist to functionally define a concept like love, for example.  “The good therapist fights darkness and seeks illumination, while romantic love is sustained by mystery and crumbles upon inspection.  I hate to be love’s executioner.”  (Yalom, 1989, p. 17)  I’m not suggesting that it’s not worthwhile to document the antecedent, behavior, and consequences of a given behavior- I am suggesting, however, that there are a limited number of conclusions that can be definitively drawn from the discriminated operant and three-term contingency embodied in the antecedent, behavior, and consequence model of behaviorism.  Theory grounded in applied behavior analysis will freely admit that behavior repertoires can appear quickly.  Behavior can spontaneously erupt with little or no direct conditioning.  Behaviorism can offer no real explanations in matters of the heart, and I submit to you that matters of the heart are where the bulk of our work resides.  The opportunity that lurks in the darkness of the unconscious mind cannot reason with our feelings, thoughts, or behavior.

 

References

Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied Behavior Analysis (2nd ed.). Upper Saddle River, NJ: Pearson Education.

Gladding, S. T. (2008). Groups: A counseling Specialty (6th ed.). Upper Saddle River, NJ: Pearson Education.

Storr, A. (1983). The essential jung. Princeton, NJ: Priceton University Press.

Yalom, I. D. (1980). Existential Psychotherapy. New York: Basic Books.

Yalom, I. D. (1989). Love’s executioner (Harper Perennial ed.). New York: HarperCollins.

Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: BasicBooks.

Yalom, I. D. (2002). The gift of therapy (Harper Perennial ed.). New York: HarperCollins.

What Kind of Therapy is Out There?


In reviewing treatments for depression, it seems the three most common, two of which are very broad, treatments are anti depressant medications, electro-convulsive therapy or ECT, and psychotherapy. Each of these treatments has their own purpose and regimen and can be combined in various ways even though they are different. In fact it is most likely because they are so different that they work well together.

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Antidepressant medication gives a therapist and a patient many options. These options have both positive and negative effects. There are different side effects with each type of medication, some tolerable, some need to be managed with other medications. It is different for everyone; this is why it is important to continue trying different combinations until an agreeable treatment plan is found. One example of medication is SSRIS, which are Selective Serotonin Reuptake Inhibitors. This medication is usually the first choice for treatment. The reasoning behind this is that SSRI’s are the most tolerated with very little side effects and most people find they work very well for them. Some side effects are headache or insomnia, but often any side effects subside in the first month. This medication allows a high amount of serotonin to be blocked in the synapse. By doing this, the cells that are neglected are resaturated allowing relief from depression symptoms.

Tricyclic anti-depressants or TCAs are a second choice in medications, if for some reason the SSRI is unable to help the patient. This medication was developed sometime during the 1950’s and 60’s. TCAs seem to be used for more moderate or severe depression because the side effects are more likely to be serious. TCAs work in the brain synapses and increase norepinephrine. Some of the side effects include dry mouth or visual focus, but the more serious side effects include things such as urinary obstruction or delirium. People who have had a lot of strokes or have been diagnosed as having seizure disorders should not be given any TCAs as medication.

MAOIs or monoamine oxidase inhibitors are another common medication prescribed to depression patients. These are generally a last choice because the side effects are often serious. MAOIs are usually effective in treating depression and were actually the first anti-depressant. It works by blocking monoamine oxidase in the brain synapses and increasing norepinephrine. MAOIs inhibit the body’s ability to break down tyramine which is found in very common foods such as wine, nuts, and chocolate. When this food is consumed while the person is taking an MAOI, it is possible for the tyramine to cause blood pressure to rise to dangerous levels.

While anti-depressants can be mixed or left as a single treatment, they do provide a lot of options to help deal with side effects or other issues that may come up.  They are always the best option; another treatment option for depression is electroconvulsive therapy or ECT.

When electroconvulsive therapy is chosen as treatment the patient receives an electrical current which is passed through the brain causing a seizure. The seizure usually continues for twenty to ninety seconds. This treatment is said to offer a patient a quick relief of their depression symptoms. A common side effect of this treatment is confusion that can last up to several hours and short term memory loss, both of which are short term.

Psychotherapy is the last type of treatment discussed and is often referred to as talk therapy. There are various types of psychotherapy such as cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. The most common type of talk therapy is the cognitive behavioral therapy. During sessions a patient not only talks about their depression, they have the opportunity to learn more about it. The patient is then able to focus on knowing what their negative patterns are and changing those into positive behaviors. Interpersonal therapists’ help their patients look at the destructive relationships a person is in that may be helping to grow the depression instead of helping to keep it at bay. Psychodynamic therapy helps a patient work through and resolves whatever internal conflicts the patient may be living with.

All of these types of psychotherapy focus on one thing, helping the patient talk through and learn how to deal with events in their lives so they don’t feel like they are drowning in depression.

Out of all of these treatments I would actually think electroconvulsive therapy to be the quickest and most effective. I can’t imagine going under sedation in order to endure treatment and then waking up not only with memory loss but also being confused about your whereabouts, among other things, even if only temporarily.

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References:

Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Depression. medicinenet.com. http://www.medicinenet.com/script/main/art.asp?articlekey=342&pf=3&page=6

Depression (Major Depression).  Mayoclinic.com. http://www.mayoclinic.com/health/depression/DS00175/METHOD=print&DSECTION=all

Major Depressive Disorder (MDD) treatment options – Examining the STAR*D Trial


When weighing the effectiveness of Major Depressive Disorder (MDD) treatment options, the most logical place to start is the largest open-label pragmatic trial ever rendered; The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.  The STAR*D trial concluded that there were no statistically significant differences in short term remission or response rates between tested treatment options, including both CBT and pharmacological remedies, but that some treatment options had advantages over others in terms of side effects and/or mean time to remission.  (Sinyor, Schaffer, & Levitt, 2010)

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There are many different flavors of CBTs intended to treat mood disorders.  Those flavors include those predominantly focused on learning theory or behavioral activation (BA), predominantly cognitive models such as Cognitive Therapy (CT/CBT), and models incorporating additional elements such as Cognitive Behavioral Analysis System Psychotherapy (CBASP) and Mindfulness-Based Cognitive Behavioral Therapy (MCBT).  (Meyer & Scott, 2008, p. 685)  CBT, when practiced by inexperienced STAR*D clinicians, was at least equally effective in short term follow-ups when compared with pharmacological remedies.  CBT was also associated with significantly fewer side effects.  Those facts alone should serve as reasonable justification in recommending CBT over all other treatment methods.

CBT was associated with longer times to remission when compared with pharmacological remedies, when they were effective, so if speed of improvement is of critical importance the client could potentially benefit the pharmacological treatment option.  Despite the apparent speed with which the pharmacological agents worked, choosing which drug is no easy task.  STAR*D found no clear medication “winner” for patients whose depression does not remit after one or more aggressive medication trials.  (Gaynes, Warden, Trivedi, & Wisniewski, 2009, p. 1443)  Matter of fact, every drug and combination of drugs showed the same effect as every other drug and drug combination.  (Leventhal & Antonuccio, 2009)  Some studies suggest that use of multiple antidepressant medications may double the likelihood of remission compared with use of a single medication.  (Blier, Ward, Tremblay, & Laberge, 2010)  Guess who funded that study?

There is increasing evidence that the biological explanation and pharmacological treatment of depressions is a failure.  STAR*D provides compelling evidence to that the placebo effect is the prime explanation for favorable outcomes that occur with antidepressants.  Of the patients that were found to respond positively to pharmacotherapy on the short term, the STAR*D study found that at the end of a year’s time almost all of the patients (97%) had either relapsed or dropped out.  (Leventhal & Antonuccio, 2009)  Even if we continue to leverage the pharmacological remedies, the long-range outcomes of clients with MDD are better when CBT is included, regardless of whether CBT is concurrent with or follows pharmacotherapy.  (Friedman, Wright, Jarrett, & Thase, 2006, p. 327)  The beneficial effects of CBT persist several years into post treatment and are strongly associated with preventing relapse (Kuyken, Dalgleish, & Holden, 2007), especially among individuals discontinuing medication use.  (Friedman, 2004)

As controversial as they are, “brain stimulation therapies” like electroconvulsive treatment (ECT) are effective in days, not weeks, and most have a higher response rate than any treatment tested in the STAR*D trial.  (Insel & Wang, 2009)  While ECT is still the gold standard in brain stimulation therapies, clinicians now have a growing list of FDA approved brain stimulation interventions. “These interventions include new modifications of ECT, vagus nerve stimulation, transcranial magnetic stimulation (TMS), magnetic seizure therapy, deep brain stimulation, transcranial direct current stimulation, implanted cortical stimulation, and others on the horizon.”  (Lisanby & Novakovic, 2009, p. 734)  Studies that utilized brain stimulation therapies to treat depression revealed significant increases in the release of norepinephrine as well as increased serotonergic activity, both of which are purported to have antidepressant effects.  (Weaver, 2009)  However, ECT is use is “limited by its invasive nature, which includes the requirement of general anesthesia and the risk of retrograde amnesia, which may be irreversible in some patients.”  (Rot, Mathew, & Charney, 2009, p. 311)  As a result, brain stimulation therapies are usually reserved for cases where depression is resistant to conventional treatments.  In addition, use of brain stimulation therapy is entirely dependent on the prescribing clinician believing in a tenuous underlying premise that norepinephrine plays a key role in depression onset and recurrence.

It would suffice to say that I favor the CBT methodology of treatment for unipolar depression, in most, if not all cases.  Personally, I would endeavor to enhance the CBT experience by utilizing cutting edge technological alternatives to traditional CBT… like virtual reality, or VR, simulations.  VR simulations are computer generated environments constructed to elicit an appropriate emotional response from clients… responses we as therapists can use in therapy.  (David, 2010)  Coupling responses that rival in vivo responses with well trained and knowledgeable CBT methods, we could usher in a new alternative to the placebo effect that passes for pharmacological intervention today.  The failure of antidepressants to provide lasting benefit, and the underlying truth that 100 years of research has failed to identify an underlying physical cause for mental disorders (including depression) leads me to believe that a “biopsychosocial model may be more useful than a disease model for conceptualizing and treating depression.”  (Leventhal & Antonuccio, 2009, p. 199)

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References

Blier, P., Ward, H. E., Tremblay, P., & Laberge, L. (2010, Mar). Combination of antidepressant medications from treatment initiation for major depressive disorder: A double-blind randomized study. The American Journal of Psychiatry, 167(3), 281-288. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1976013231&sid=18&Fmt=4&clientId=4683&RQT=309&VName=PQD

David, D. (2010, Mar). Cutting edge deveopments in psychology: Virtual reality applications. Interview with two leading experts. Journal of Cognitive and Behavioral Psychotherapies, 10(1), 115-126. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2010171911&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, E. S., Wright, J. H., Jarrett, R. B., & Thase, M. E. (2006, May). Combining cognitive therapy and medication for mood disorders. Psychiatric Annals, 36(5), 320-329. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1069483751&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, M. A. (2004, Spring). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science and Practice, 11(1), 47-68. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=40&did=526558591&SrchMode=1&sid=5&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272666830&clientId=4683

Gaynes, B. N., Warden, D., Trivedi, M. H., & Wisniewski, S. R. (2009, Nov). What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatric Services, 60(11), 1439-1445. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1921563151&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Insel, T. R., & Wang, P. S. (2009, Nov). The STAR*D trial: Revealing the need for better treatments. Psychiatric Services, 60(11), 1466-1467. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=28&did=1921563061&SrchMode=1&sid=6&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272667182&clientId=4683

Kuyken, W., Dalgleish, T., & Holden, E. R. (2007, Jan). Advances in cognitive-behavioural therapy for unipolar depression. Canadian Journal of Psychiatry, 52(1), 5-14. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1203220561&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Leventhal, A. M., & Antonuccio, D. O. (2009). On chemical imbalances, antidepressants, and the diagnosis of depression. Ethical Human Psychology and Psychiatry, 11(3), 199-214. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1923231211&sid=19&Fmt=3&clientId=4683&RQT=309&VName=PQD

Lisanby, S. H., & Novakovic, V. (2009, Jun). Brain stimulation therapies for clinicians. The American Journal of Psychiatry, 166(6), 734-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1738370431&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Meyer, T. D., & Scott, J. (2008, Nov). Cognitive behavioural therapy for mood disorders. Behavioural and Cognitive Psychotherapy, 36(6), 685-693. doi: 10.1017/S1352465808004761

Rot, M. A., Mathew, S. J., & Charney, D. S. (2009, Feb 3). Neurobiological mechanisms in major depressive disorder. Canadian Medical Association. Journal, 180(3), 305-313. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1634710771&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Sinyor, M., Schaffer, A., & Levitt, A. (2010, Mar). The sequenced treatment alternatives to relieve depression (STAR*D) trial: A review. Canadian Journal of Psychiatry, 55(3), 126-136. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2016794701&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Weaver, D. F. (2009, Summer). Self-induced “therapeutic seizures” for the treatment of depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(3), 355-357. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=71&did=1868802651&SrchMode=1&sid=14&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272668233&clientId=4683

Separation Anxiety Disorder (SAD)


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In order to qualify for a DSM-IV-TR (2000) diagnosis of Separation Anxiety Disorder (SAD; 309.21), a client must present with the following essential features:

A)    Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attacked, as evidenced by three (or more) of the following:

  1. Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
  2. Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
  3. Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
  4. Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
  5. Persistently and excessively fearful or reluctant to be along or without major attachment figures at home or without significant adults in other settings
  6. Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
  7. Repeated nightmares involving themes of separation
  8. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

B)    The disturbance must last for a period of at least 4 weeks.

C)    The disturbance must begin before age 18.

D)    The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.

E)     The disturbance does not occur exclusively during the course of a Pervasive Development Disorder (PDD), Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 125)

Separation Anxiety Disorder (SAD) is not uncommon; prevalence estimates average about 4% in children and young adolescents.  SAD decreases in prevalence as kids get older.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 123)  Some researchers argue that SAD is actually an early manifestation of panic disorder, rather than just a risk factor or precursor.  (Jurbergs & Ledley, 2005)

Treatment of SAD often involves a multimodal approach that may include psycho-education of the patient and family, school consultation and intervention, pediatrician consultation and pharmacotherapy, and cognitive-behavior therapy (CBT).  Research has repeatedly demonstrated the efficacy of CBT for children with SAD, supporting it as the best-proven treatment.  (Jurbergs & Ledley, 2005)  CBT has become a respected and empirically established model of psychotherapy in adults.  The fundamental principles of CBT can be applied to children with developmental modifications.  David Dia’s (2001) case study of a six year old boy named “Colt” serves as a great example.  Utilizing family education, progressively more difficult stress scenarios, and a token/exchange system; Colt’s belief was challenged and modified.  (Dia, 2001)

Although the cognitive technique of guided discovery and education proved fruitful in Colt’s case, I would underscore the importance of modifying CBT methods that were traditionally designed for adult patients.  Grover and associates (2006) provide the following examples of modification:

Relaxation and breathing techniques can be adapted for the younger child by using balloon (e.g., breath in and make your tummy fill up like a balloon) and robot/rag doll (e.g., tense your muscles like a robot, relax like a rag doll) metaphors. Depending on the cognitive level of the child, cognitive restructuring techniques may be simplified to teaching the child self-statements like, “Everything will be OK,” or, “I can handle my worries by myself.” One 9-year-old boy with SAD liked to use the coping statement, “Mom has always come back for me before.”  (Grover, Hughes, Bergman, & Kingery, 2006)

Pharmacotherapy should be used in conjunction with CBT only when the child’s symptoms have not responded to CBT interventions alone.  Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines have all been used to treat a number of anxiety disorders in children, including SAD, but no medications have specific indications for SAD.  (Jurbergs & Ledley, 2005)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Dia, D. A. (2001, May). Cognitive-behavioral therapy with a six-year-old boy with separation anxiety disorder: A case study. Health & Social Work, 26(2), 125-129. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=73283346&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Grover, R. L., Hughes, A. A., Bergman, R. L., & Kingery, J. N. (2006, Fall). Treatment modifications based on childhood anxiety diagnosis: Demonstrating the flexibility in manualized treatment. Journal of Cognitive Psychotherapy, 20(3), 275-287. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1126879061&sid=6&Fmt=3&clientId=4683&RQT=309&VName=PQD

Jurbergs, N., & Ledley, D. R. (2005, Sep). Separation anxiety disorder. Psychiatric Annals, 35(9), 728-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=905192971&sid=6&Fmt=4&clientId=4683&RQT=309&VName=PQD