PSYCHODYNAMIC EMOTION FOCUSED THERAPIES: THE NEXT PSYCHIATRIC FRONTIER

ALAN EPPEL MB, FRCPC

Due to the increasing recognition among psychiatrists of the constraints of

psychopharmacological treatment of psychiatric disorders, there has been

an intensified interest in psychotherapies.

Current research is focused on identifying which types of patients respond best to the various psychotherapeutic modalities.

New forms of psychotherapy have evolved to respond to therapeutic gaps. Well-established therapies include cognitive behavior therapy, emotion focused therapy, cognitive processing therapy, interpersonal psychotherapy, and psychodynamic psychotherapy.

Over the past five decades there have been considerable advances to the psychodynamic paradigm.

 Freud's intrapsychic conflict model has evolved through object relations theory to attachment-based and relational psychotherapies.

Bowlby's attachment theory has had a profound influence within psychiatry and psychology and is one of the foundational components within the practice of psychiatry.

Discoveries in Affective Neuroscience, particularly the work of Jaak Panksepp, have provided a deeper understanding of the human affective systems and their application to psychotherapy.

Therapeutic interventions  are now conceptualized much more in attachment and relational terms; the language of object relations has been translated into new formulations.

There have been major changes in technique leading to more rapid access to unconscious emotions. There is greater emphasis on using the therapeutic dyad as a major accelerator of change. 
The previous emphasis on interpretation has been replaced by the uncovering of core emotions and the processing of these experientially within the therapeutic session.

New forms of shorter term and accelerated psychodynamic psychotherapy have been developed building upon the work of Michael Balint and David Malan in the UK. Intensive Short-term Dynamic Psychotherapy was developed by Habib Davanloo in Montreal and represented a dramatic breakthrough in accelerating the process of therapy.

Two of Davanloo's students Alan Abbass in Halifax and Diana Fosha in New York  went on to further develop and apply these methods. Alan Abbass continues to practice and teach Davanloo's approach. This involves vigorous confrontation of defenses and focus on the transference. He has made major contributions by publishing meta-analyses, systematic reviews and outcome studies. 

Recently Abbass led a Cochrane review of 33 studies  involving 2173 patients with a rangeof common psychiatric disorders. Primary outcomes were reductions in general, somatic, anxiety and depressive symptoms, as well as change in interpersonal problems and social adjustment. Except for somatic measures in the short-term, all outcome categories suggested significantly greater improvement in the treatment versus the control groups.

New York psychologist Diana Fosha has applied attachment theory and affective neuroscience in developing AEDP: Accelerated Experiential Dynamic Psychotherapy.

 In her ground-breaking book "The Transforming Power of Affect" she describes techniques that rapidly bypass defenses to reach deep emotions of sadness, anger, grief, rage, and joy. Adopting the attachment paradigm Fosha provides a secure base for the patient by means of active engagement, attunement, and validation. 

Tracking moment to moment affect is done by paying exquisite attention to minute signs of affective shift, body posture and facial expression.

The therapist makes empathy explicit by the expression of compassion, warmth and appreciation. Implicit empathy is conveyed by matching tone, non-linguistic verbalizations, eye gaze, pacing and rhythm. 

Disclosure of the positive impact the patient has on the therapist is a powerful tool to foster attachment and provides a corrective emotional experience.

Fosha has concluded that Interpretation and insight do not lead to change rather it is the experience of previously "unbearable affect" in the present moment,  within the securely attached dyadic therapeutic relationship that leads to healing and inner transformation.

References:

Abbass A, Kisely S, Town J, Leichsenring F et al. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Collaboration 2014.

Bowlby, J (1977) The Making and Breaking of Affectional Bonds British J.

Psychiatry 130,421-31

Davanloo, H (1990) Unlocking the unconscious: Selected papers of Habib

Davanloo. New York. Wiley

Fonagy, P (2001) Attachment Theory and Psychoanalysis. New York. Other Press

Fosha, D (2000) The Transforming Power of Affect. New York. Basic Books.

Panksepp, J (1998) Affective Neuroscience: the foundations of human and animal

emotions. Oxford University Press.

Panksepp, J (2003) Feeling the Pain of Social Loss. Science v.302 237-239

REPLICATING ROSENHAN’S STUDY: A METHODOLOGICAL AND ETHICAL ARGUMENT AND PROPOSAL

Abraham Rudnick, MD, PhD, CPRP, FRCPC, CCPE,

Professor, Department of Psychiatry and Behavioural

Neurosciences, McMaster University                            

Email: harudnick@hotmail.com

Abstract: The quality of inpatient mental health care, particularly in psychiatric hospitals, has been criticized for many years to date. A famous critique of such care is related to Rosenhan’s study (published in 1973), which demonstrated unsound psychiatric diagnosis and suboptimal inpatient care. Attempting to replicate this study nowadays may be informative, yet current research standards would not allow conducting it without modification, as it would now be widely considered methodologically unsound and ethical unacceptable. In this paper I examine Rosenhan’s study in light of contemporary methodological and ethical standards and propose modifications to it for a sound replication attempt.

Keywords: Ethics, methodology, quality of mental health care, Rosenhan.

Disclosure: None

Acknowledgement: The inspiration for this article was provided by my correspondence with a patient advocate.

The quality of inpatient mental health care, particularly in psychiatric hospitals, has been criticized for many years to date. This has been the case at least since the mid-19th century when psychiatric asylums were overcrowded, to which a reaction starting in the mid-20th century was de-institutionalization and later provision of more and better community supports (Carling 1995). As part of this trend, a famous critique of such institutional mental health care is related to Rosenhan’s study, which demonstrated unsound psychiatric diagnosis and suboptimal inpatient care (Rosenhan 1973). Rosenhan studied the experience of 8 so-called sane people (some of whom were mental health care professionals) who falsely reported hearing voices, i.e., having auditory hallucinations, in order to be admitted to a psychiatric hospital; once admitted, they stopped reporting hearing voices but were all still provided care for, and eventually discharged with, a diagnosis of schizophrenia. The principal conclusions from this study were that psychiatric diagnosis is unsound and that inpatient care in psychiatric hospitals is suboptimal. 

Attempting to replicate Rosenhan’s study these days may be informative, e.g., to examine psychiatric diagnosis and inpatient care in contemporary psychiatric hospitals, with the hope that due to arguable improvements in psychiatric diagnosis (American Psychiatric Association 2013) and quality of care (Jayaram 2015) there has been improvement in diagnosis and care in psychiatric hospitals. Yet current research standards would not allow conducting Rosenhan’s study without modification, as it would now be widely considered methodologically unsound and ethical unacceptable. For example, methodologically, although the study sampled various psychiatric hospitals, it did not specifically assess – and hence was not controlled for – clinical skills of the service providers. And ethically, most of the 8 participants were not identified to the participating hospitals, and were provided care for schizophrenia that they did not have, hence risking unnecessarily prolonged negative consequences such as serious adverse effects of medications and stigma. Of note is that there was no standardized regulation then of human research, as such regulation started in the late 1970s following the Belmont Report (http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html#).

To replicate this study nowadays, it would have to meet current methodological and ethical human research standards. I propose here a modified study design. The study would consist of a randomized controlled multi-site trial in psychiatric hospitals and in psychiatry units of general hospitals with a statistically powered (sufficiently sized) sample of trained actors simulating schizophrenia; half of the actors simulating auditory hallucinations with other schizophrenia-related symptoms and another half simulating auditory hallucinations without other symptoms. Mixed (quantitative and qualitative) evaluation methods would be used, such as reporting of admission and discharge diagnoses, care provided and length of admission, as well as related experiences of the actors, other psychiatric inpatients – who may sometimes identify simulators of their own mental illness better than staff do (Rosenhan 1973) – admitted to the study units, and involved staff. Informed consent of the involved patients (actors and others) and research ethics board approval, including for initial deceit (of staff), would be required. Other study designs may also merit consideration.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Publications, 2013.

Carling PJ. Return to Community: Building Support Systems for People with Psychiatric Disabilities. New York: Guilford, 1995.

Jayaram G (ed). Practicing Patient Safety in Psychiatry. Oxford: Oxford University Press, 2015.

Rosenhan DL. On being sane in insane places. Science 1973. 179(4070):250-8.

ARIPIPRAZOLE in DEPRESSION and ANXIETY: BUYER BEWARE!

                              ALAN EPPEL MB, FRCPC

Attached to the cover of a recent issue of the Canadian Journal of Psychiatry was an advertisement promoting the use of aripiprazole for the treatment of depression.

The advertisement was addressed to me personally and recommended that aripiprazole be considered early on in the treatment algorithm for depression. The advertisement implied that  adjunctive aripiprazole be considered after 2 to 4 weeks of nonresponse to an antidepressant.

The use of second-generation antipsychotics for the treatment of mood and anxiety disorders has skyrocketed in the past decade. While there is some evidence for efficacy claims are frequently made without a balanced consideration of the risks versus benefits.

SIDE EFFECTS

The main serious side effects antipsychotic medications are 1) metabolic syndrome and 2) extrapyramidal symptoms and tardive dyskinesia. 

Metabolic Syndrome Diagnostic Criteria: International Diabetes Federation Criterion A plus two of other four items.

A.

Waist circumference

men >37 inches; women >31.5 inches 

 B. 

1. Fasting triglycerides >150 mg/dl

 2. High-density lipoprotein Men: <40 mg/dl Women: <50 mg/dl

 3. Systolic blood pressure/diastolic blood pressure >130/85 mmHg, or on antihypertensive medication 

4. Fasting glucose >100 mg/dl, or on insulin or hypoglycemic medication. 

 In a meta-analysis conducted by Spielmans et al. adjunctive aripiprazole had an effect size of only 0.35 considered, small to moderate. 

 Aripiprazole was associated with akathisia with the number needed to harm of NNH=4.  With regard to weight gain NNH= 29. Average weight gain across a number of trials was one kilogram and ranged from 0.42 1.67 kg.

Troublesome methodological deficiencies were identified in these studies. The Federal Drug Administration expressed concern about a number of protocol violations in one of the aripiprazole studies. This concerned the number of participants who used prohibited medications during the trial.

The authors note that at the time of publication there were no trials that directly compared adjunctive atypical antipsychotic medication to other treatment strategies such as such adjunctive lithium, switching the antidepressant, or adding psychotherapy.

In a study of second generation antipsychotics in 342 youth, Carbon et al found that 15.2% developed drug-induced parkinsonism. 

SGA-group drug-induced parkinsonism rates were as follows:

quetiapine = 1.5%, olanzapine = 13.8%,

risperidone = 16.1%, ziprasidone = 20.0%,

and aripiprazole = 27.3%.

Treatment-emergent dyskinesia ranged from 4.5% with aripiprazole, to 15.5% with olanzapine.

Cloud et al in a review  noted tardive dyskinesia prevalence rates of 13 % among patients on SGAs and 32 % among patients on first-generation agents. One included review of 12 trials reported  the annual incidence of TD to be 3.9 % for SGAs and 5.5 % for first-generation drugs

CONCLUSION

Contrary to early hopes, second generation antipsychotics do have significant rates of serious side effects. In the treatment of schizophrenia and related psychoses these risks may be outweighed by the potential benefits.

However the risk benefit equation provides  no justification for the use of SGAs in the  treatment of mood or anxiety as first, second or even third line agents.

References:

1. Spielmans GI et al. Adjunctive atypical antipsychotic treatment for major

depressive  disorder: a meta-analysis of depression, quality of life, and

safety outcomes. PLoS Med. 2013;10(3):e1001403. doi: 10.1371/journal.pmed.1001403.

2. Carbon M  et al. Neuromotor Adverse Effects in 342 Youth During 12 Weeks of Naturalistic Treatment With 5 Second-Generation Antipsychotics.

J Am Acad Child Adolesc Psychiatry. 2015 Sep;54(9):718-727

                    3.Cloud LJ, Zutshi D, Factor SA. Tardive dyskinesia: therapeutic options for 

                    an increasingly common disorder. Neurotherapeutics. 2014 Jan;11(1):166-76.