Category: Mental Health Treatment

What is a Serotonin-Norepinephrine-Dopamine Reuptake Inhibitor

Published on by Andrew Marshall1 Comment

Introduction

A serotonin–norepinephrine–dopamine reuptake inhibitor (SNDRI), also known as a triple reuptake inhibitor (TRI), is a type of drug that acts as a combined reuptake inhibitor of the monoamine neurotransmitters serotonin, norepinephrine, and dopamine. It does this by concomitantly inhibiting the serotonin transporter (SERT), norepinephrine transporter (NET), and dopamine transporter (DAT), respectively. Inhibition of the reuptake of these neurotransmitters increases their extracellular concentrations and, therefore, results in an increase in serotonergic, adrenergic, and dopaminergic neurotransmission. The naturally-occurring and potent SNDRI cocaine is widely used recreationally and often illegally for the euphoric effects it produces.

Other SNDRIs were developed as potential antidepressants and treatments for other disorders, such as obesity, cocaine addiction, attention-deficit hyperactivity disorder (ADHD), and chronic pain. They are an extension of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) whereby the addition of dopaminergic action is thought to have the possibility of heightening therapeutic benefit. However, increased side effects and abuse potential are potential concerns of these agents relative to their SSRI and SNRI counterparts.

The SNDRIs are similar to non-selective monoamine oxidase inhibitors (MAOIs) such as phenelzine and tranylcypromine in that they increase the action of all three of the major monoamine neurotransmitters. They are also similar to serotonin–norepinephrine–dopamine releasing agents (SNDRAs) like MDMA (“ecstasy”) and α-ethyltryptamine (αET) for the same reason, although they act via a different mechanism and have differing physiological and qualitative effects.

Although their primary mechanisms of action are as NMDA receptor antagonists, ketamine and phencyclidine are also SNDRIs and are similarly encountered as drugs of abuse.

Indications

Depression

Major depressive disorder (MDD) is the foremost reason supporting the need for development of an SNDRI. According to the World Health Organisation (WHO), depression is the leading cause of disability and the 4th leading contributor to the global burden of disease in 2000. By the year 2020, depression is projected to reach 2nd place in the ranking of DALYs (disability adjusted life years).

About 16% of the population is estimated to be affected by major depression, and another 1% is affected by bipolar disorder, one or more times throughout an individual’s lifetime. The presence of the common symptoms of these disorders are collectively called ‘depressive syndrome’ and includes a long-lasting depressed mood, feelings of guilt, anxiety, and recurrent thoughts of death and suicide. Other symptoms including poor concentration, a disturbance of sleep rhythms (insomnia or hypersomnia), and severe fatigue may also occur. Individual patients present differing subsets of symptoms, which may change over the course of the disease highlighting its multifaceted and heterogeneous nature. Depression is often highly comorbid with other diseases, e.g. cardiovascular disease (myocardial infarction, stroke), diabetes, cancer, Depressed subjects are prone to smoking, substance abuse, eating disorders, obesity, high blood pressure, pathological gambling and internet addiction, and on average have a 15 to 30 year shorter lifetime compared with the general population.

Major depression can strike at virtually any time of life as a function of genetic and developmental pre-disposition in interaction with adverse life-events. Although common in the elderly, over the course of the last century, the average age for a first episode has fallen to ~30 years. However, depressive states (with subtly different characteristics) are now frequently identified in adolescents and even children. The differential diagnosis (and management) of depression in young populations requires considerable care and experience; for example, apparent depression in teenagers may later transpire to represent a prodromal phase of schizophrenia.

The ability to work, familial relationships, social integration, and self-care are all severely disrupted.

The genetic contribution has been estimated as 40-50%. However, combinations of multiple genetic factors may be involved because a defect in a single gene usually fails to induce the multifaceted symptoms of depression.

Pharmacotherapy

There remains a need for more efficacious antidepressant agents. Although two-thirds of patients will ultimately respond to antidepressant treatment, one-third of patients respond to placebo, and remission is frequently sub-maximal (residual symptoms). In addition to post-treatment relapse, depressive symptoms can even recur in the course of long-term therapy (tachyphylaxis). Also, currently available antidepressants all elicit undesirable side-effects, and new agents should be divested of the distressing side-effects of both first and second-generation antidepressants.

Another serious drawback of all antidepressants is the requirement for long-term administration prior to maximal therapeutic efficacy. Although some patients show a partial response within 1–2 weeks, in general one must reckon with a delay of 3–6 weeks before full efficacy is attained. In general, this delay to onset of action is attributed to a spectrum of long-term adaptive changes. These include receptor desensitisation, alterations in intracellular transduction cascades and gene expression, the induction of neurogenesis, and modifications in synaptic architecture and signalling.

Depression has been associated with impaired neurotransmission of serotonergic (5-HT), noradrenergic (NE), and dopaminergic (DA) pathways, although most pharmacologic treatment strategies directly enhance only 5-HT and NE neurotransmission. In some patients with depression, DA-related disturbances improve upon treatment with antidepressants, it is presumed by acting on serotonergic or noradrenergic circuits, which then affect DA function. However, most antidepressant treatments do not directly enhance DA neurotransmission, which may contribute to residual symptoms, including impaired motivation, concentration, and pleasure.

Preclinical and clinical research indicates that drugs inhibiting the reuptake of all three of these neurotransmitters can produce a more rapid onset of action and greater efficacy than traditional antidepressants.

DA may promote neurotrophic processes in the adult hippocampus, as 5-HT and NA do. It is thus possible that the stimulation of multiple signalling pathways resulting from the elevation of all three monoamines may account, in part, for an accelerated and/or greater antidepressant response.

Dense connections exist between monoaminergic neurons. Dopaminergic neurotransmission regulates the activity of 5-HT and NE in the dorsal raphe nucleus (DR) and locus coeruleus (LC), respectively. In turn, the ventral tegmental area (VTA) is sensitive to 5-HT and NE release.

In the case of SSRIs, the promiscuity among transporters means that there may be more than a single type of neurotransmitter to consider (e.g. 5-HT, DA, NE, etc.) as mediating the therapeutic actions of a given medication. MATs are able to transport monoamines other than their “native” neurotransmitter. It was advised to consider the role of the organic cation transporters (OCT) and the plasma membrane monoamine transporter (PMAT).

To examine the role of monoamine transporters in models of depression DAT, NET, and SERT knockout (KO) mice and wild-type littermates were studied in the forced swim test (FST), the tail suspension test, and for sucrose consumption. The effects of DAT KO in animal models of depression are larger than those produced by NET or SERT KO, and unlikely to be simply the result of the confounding effects of locomotor hyperactivity; thus, these data support re-evaluation of the role that DAT expression could play in depression and the potential antidepressant effects of DAT blockade.

The SSRIs were intended to be highly selective at binding to their molecular targets. However it may be an oversimplification, or at least controversial in thinking that complex psychiatric (and neurological) diseases are easily solved by such a monotherapy. While it may be inferred that dysfunction of 5-HT circuits is likely to be a part of the problem, it is only one of many such neurotransmitters whose signalling can be affected by suitably designed medicines attempting to alter the course of the disease state.

Most common CNS disorders are highly polygenic in nature; that is, they are controlled by complex interactions between numerous gene products. As such, these conditions do not exhibit the single gene defect basis that is so attractive for the development of highly-specific drugs largely free of major undesirable side-effects (“the magic bullet”). Second, the exact nature of the interactions that occur between the numerous gene products typically involved in CNS disorders remain elusive, and the biological mechanisms underlying mental illnesses are poorly understood.

Clozapine is an example of a drug used in the treatment of certain CNS disorders, such as schizophrenia, that has superior efficacy precisely because of its broad-spectrum mode of action. Likewise, in cancer chemotherapeutics, it has been recognised that drugs active at more than one target have a higher probability of being efficacious.

In addition, the nonselective MAOIs and the TCA SNRIs are widely believed to have an efficacy that is superior to the SSRIs normally picked as the first-line choice of agents for/in the treatment of MDD and related disorders. The reason for this is based on the fact that SSRIs are safer than nonselective MAOIs and TCAs. This is both in terms of there being less mortality in the event of overdose, but also less risk in terms of dietary restrictions (in the case of the nonselective MAOIs), hepatotoxicity (MAOIs) or cardiotoxicity (TCAs).

Applications other than Depression

  • Alcoholism (c.f. DOV 102,677)
  • Cocaine addiction (e.g., indatraline)
  • Obesity (e.g., amitifadine, tesofensine)
  • Attention-deficit hyperactivity disorder (ADHD) (c.f. NS-2359, EB-1020)
  • Chronic pain (c.f. bicifadine)
  • Parkinson’s disease

List of SNDRIs

Approved pharmaceuticals

  • Mazindol (Mazanor, Sanorex) — anorectic; ki is 50 nM for SERT, 18 nM for NET, 45 nM for DAT[38]
  • Nefazodone (Serzone, Nefadar, Dutonin) — antidepressant; non-selective; ki is 200 nM at SERT, 360 nM at NET, 360 nM at DAT
  • Nefopam (ki SER/NE/DA = 29/33/531 nM) Informative review.

Sibutramine (Meridia) is a withdrawn anorectic that is an SNDRI in vitro with ki values of 298 nM at SERT, 5451 at NET, 943 nM at DAT. However, it appears to act as a prodrug in vivo to metabolites that are considerably more potent and possess different ratios of monoamine reuptake inhibition in comparison, and in accordance, sibutramine behaves contrarily as an SNRI (73% and 54% for norepinephrine and serotonin reuptake inhibition, respectively) in human volunteers with only very weak and probably inconsequential inhibition of dopamine reuptake (16%).

Venlafaxine (Effexor) is sometimes referred to as an SNDRI, but is extremely imbalanced with ki values of 82 nM for SERT, 2480 nM for NET, and 7647 nM for DAT, with a ratio of 1:30:93. It may weakly inhibit the reuptake of dopamine at high doses.

Coincidental

  • Esketamine (Ketanest S) — anesthetic; S-enantiomer of ketamine; weak SNDRI action likely contributes to effects and abuse potential
  • Ketamine (Ketalar) — anesthetic and dissociative drug of abuse; weak SNDRI action likely contributes to effects and abuse potential
  • Phencyclidine (Sernyl) — discontinued anaesthetic and dissociative psychostimulant drug of abuse; SNDRI action likely contributes to effects and abuse potential
  • Tripelennamine (Pyribenzamine) — antihistamine; weak SNDRI; sometimes abused for this reason
  • Mepiprazole

Undergoing Clinical Trials

  • Ansofaxine (LY03005/LPM570065). Completed Phase 2 & 3 trials. FDA accepted NDA application.
  • Centanafadine (EB-1020) — see here for details Archived 2012-05-31 at the Wayback Machine 1 to 6 to 14 ratio for NDS. Completed Phase 3 trials for ADHD.
  • OPC-64005 — In phase 2 trials (2022)
  • Lu AA37096 — see here (SNDRI and 5-HT6 modulator)
  • NS-2360 — principle metabolite of tesofensine
  • Tesofensine (NS-2330) (2001) In trials for obesity.

Failed Clinical Trials

  • Bicifadine (DOV-220,075) (1981)
  • BMS-866,949
  • Brasofensine (NS-2214, BMS-204,756) (1995)
  • Diclofensine (Ro 8–4650) (1982)
  • DOV-216,303 (2004)
  • EXP-561 (1965)
  • Liafensine (BMS-820,836)
  • NS-2359 (GSK-372,475)
  • RG-7166 (2009–2012)
  • SEP-227,162
  • SEP-228,425
  • SEP-432 aka SEP-228432, CID:58954867
  • Amitifadine (DOV-21,947, EB-1010) (2003)
  • Dasotraline (SEP-225,289)
  • Lu AA34893 (SNDRI and 5-HT2A, α1, and 5-HT6 modulator)
  • Tedatioxetine (Lu AA24530) — SNDRI and 5-HT2C, 5-HT3, 5-HT2A, and α1 modulator

Designer Drugs

  • 3-Methyl-PCPy
  • Naphyrone (O-2482, naphthylpyrovalerone, NRG-1) (2006)
  • 5-APB

Toxicological

Toxicological screening is important to ensure safety of the drug molecules. In this regard, the p m-dichloro phenyl analogue of venlafaxine was dropped from further development after its potential mutagenicity was called into question. The mutagenicity of this compound is still doubtful though. It was dropped for other reasons likely related to speed at which it could be released onto the market relative to the more developed compound venlafaxine. More recently, the carcinogenicity of PRC200-SS was likewise reported.

(+)-CPCA (“nocaine”) is the 3R,4S piperidine stereoisomer of (phenyltropane based) RTI-31. It is non addictive, although this might be due to it being a NDRI, not a SNDRI. The β-naphthyl analogue of “Nocaine” is a SNDRI though in the case of both the SS and RR enantiomers. Consider the piperidine analogues of brasofensine and tesofensine. These were prepared by NeuroSearch (In Denmark) by the chemists Peter Moldt (2002), and Frank Wätjen (2004–2009). There are four separate isomers to consider (SS, RR, S/R and R/S). This is because there are two chiral carbon sites of asymmetry (means 2 to the power of n isomers to consider where n is the number of chiral carbons). They are therefore a diastereo(iso)meric pair of racemers. With a racemic pair of diastereomers, there is still the question of syn (cis) or anti (trans). In the case of the phenyltropanes, although there are four chiral carbons, there are only eight possible isomers to consider. This is based on the fact that the compound is bicyclic and therefore does not adhere to the equation given above.

It is complicated to explain which isomers are desired. For example, although Alan P. Kozikowski showed that R/S nocaine is less addictive than SS Nocaine, studies on variously substituted phenyltropanes by F. Ivy Carroll et at. revealed that the ββ isomers were less likely to cause convulsions, tremor and death than the corresponding trans isomers (more specifically, what is meant is the 1R,2R,3S isomers). While it does still have to be conceded that RTI-55 caused death at a dosage of 100 mg/kg, its therapeutic index of safety is still much better than the corresponding trans isomers because it is a more potent compound.

In discussing cocaine and related compounds such as amphetamines, it is clear that these psychostimulants cause increased blood pressure, decreased appetite (and hence weight loss), increased locomotor activity (LMA) etc. In the United States, cocaine overdose is one of the leading causes of ER admissions each year due to drug overdose. People are at increased risk of heart attack and stroke and also present with an array of psychiatric symptoms including anxiety & paranoia etc. On removal of the 2C tropane bridge and on going from RTI-31 to the simpler SS and RS Nocaine it was seen that these compounds still possessed activity as NDRIs but were not powerful psychostimulants. Hence, this might be viewed as a strategy for increasing the safety of the compounds and would also be preferable to use in patients who are not looking to achieve weight loss.

In light of the above paragraph, another way of reducing the psychomotor stimulant and addictive qualities of phenyltropane stimulants is in picking one that is relatively serotonergic. This strategy was employed with success for RTI-112.

Another thing that is important and should be mentioned is the risk for serotonin syndrome when incorporating the element of 5-HT transporter inhibition into a compound that is already fully active as a NDRI (or vice versa). The reasons for serotonin syndrome are complicated and not fully understood.

Addiction

Drug addiction may be regarded as a disease of the brain reward system. This system, closely related to the system of emotional arousal, is located predominantly in the limbic structures of the brain. Its existence was proved by demonstration of the “pleasure centres,” that were discovered as the location from which electrical self-stimulation is readily evoked. The main neurotransmitter involved in the reward is dopamine, but other monoamines and acetylcholine may also participate. The anatomical core of the reward system are dopaminergic neurons of the ventral tegmentum that project to the nucleus accumbens, amygdala, prefrontal cortex and other forebrain structures.

There are several groups of substances that activate the reward system and they may produce addiction, which in humans is a chronic, recurrent disease, characterised by absolute dominance of drug-seeking behaviour.

According to various studies, the relative likelihood of rodents and non-human primates self-administering various psychostimulants that modulate monoaminergic neurotransmission is lessened as the dopaminergic compounds become more serotonergic.

The above finding has been found for amphetamine and some of its variously substituted analogues including PAL-287 etc.

RTI-112 is another good example of the compound becoming less likely to be self-administered by the test subject in the case of a dopaminergic compound that also has a marked affinity for the serotonin transporter.

WIN 35428, RTI-31, RTI-51 and RTI-55 were all compared and it was found that there was a negative correlation between the size of the halogen atom and the rate of self-administration (on moving across the series). Rate of onset was held partly accountable for this, although increasing the potency of the compounds for the serotonin transporter also played a role.

Further evidence that 5-HT dampens the reinforcing actions of dopaminergic medications comes from the co-administration of psychostimulants with SSRIs, and the phen/fen combination was also shown to have limited abuse potential relative to administration of phentermine only.

NET blockade is unlikely to play a major role in mediating addictive behaviour. This finding is based on the premise that desipramine is not self-administered, and also the fact that the NRI atomoxetine was not reinforcing. However, it was still shown to facilitate dopaminergic neurotransmission in certain brain regions such as in the core of the prefrontal cortex (PFC).

Relation to Cocaine

Cocaine is a short-acting SNDRI that also exerts auxiliary pharmacological actions on other receptors. Cocaine is a relatively “balanced” inhibitor, although facilitation of dopaminergic neurotransmission is what has been linked to the reinforcing and addictive effects. In addition, cocaine has some serious limitations in terms of its cardiotoxicity due to its local anaesthetic activity. Thousands of cocaine users are admitted to emergency units in the USA every year because of this; thus, development of safer substitute medications for cocaine abuse could potentially have significant benefits for public health.

Many of the SNDRIs currently being developed have varying degrees of similarity to cocaine in terms of their chemical structure. There has been speculation over whether the new SNDRIs will have an abuse potential like cocaine does. However, for pharmacotherapeutical treatment of cocaine addiction it is advantageous if a substitute medication is at least weakly reinforcing because this can serve to retain addicts in treatment programmes:

… limited reinforcing properties in the context of treatment programs may be advantageous, contributing to improved patient compliance and enhanced medication effectiveness.

However, not all SNDRIs are reliably self-administered by animals. Examples include:

  • PRC200-SS was not reliably self-administered.
  • RTI-112 was not self-administered because at low doses the compound preferentially occupies the SERT and not the DAT.
  • Tesofensine was also not reliably self-administered by human stimulant addicts.
  • The nocaine analogue JZAD-IV-22 only partly substituted for cocaine in animals, but produced none of the psychomotor activation of cocaine, which is a trait marker for stimulant addiction.

Legality

Cocaine is a controlled drug (Class A in the UK; Schedule II in the USA); it has not been entirely outlawed in most countries, as despite having some “abuse potential” it is recognised that it does have medical uses.

Brasofensine was made “class A” in the UK under the MDA (misuse of drugs act). The semi-synthetic procedure for making BF uses cocaine as the starting material.

Naphyrone first appeared in 2006 as one of quite a large number of analogues of pyrovalerone designed by the well-known medicinal chemist P. Meltzer et al. When the designer drugs mephedrone and methylone became banned in the United Kingdom, vendors of these chemicals needed to find a suitable replacement. Mephedrone and methylone affect the same chemicals in the brain as a SNDRI, although they are thought to act as monoamine releasers and not act through the reuptake inhibitor mechanism of activity. A short time later, mephedrone and methylone were banned (which had become quite popular by the time they were illegalised), naphyrone appeared under the trade name NRG-1. NRG-1 was promptly illegalised, although it is not known if its use resulted in any hospitalisations or deaths.

Role of Monoamine Neurotransmitters

Monoamine Hypothesis

The original monoamine hypothesis postulates that depression is caused by a deficiency or imbalances in the monoamine neurotransmitters (5-HT, NE, and DA). This has been the central topic of depression research for approximately the last 50 years; it has since evolved into the notion that depression arises through alterations in target neurons (specifically, the dendrites) in monoamine pathways.

When reserpine (an alkaloid with uses in the treatment of hypertension and psychosis) was first introduced to the West from India in 1953, the drug was unexpectedly shown to produce depression-like symptoms. Further testing was able to reveal that reserpine causes a depletion of monoamine concentrations in the brain. Reserpine’s effect on monoamine concentrations results from blockade of the vesicular monoamine transporter, leading to their increased catabolism by monoamine oxidase. However, not everyone has been convinced by claims that reserpine is depressogenic, some authors (David Healy in particular) have even claimed that it is antidepressant.

Tetrabenazine, a similar agent to reserpine, which also depletes catecholamine stores, and to a lesser degree 5-HT, was shown to induce depression in many patients.

Iproniazid, an inhibitor of MAO, was noted to elevate mood in depressed patients in the early 1950s, and soon thereafter was shown to lead to an increase in NA and 5-HT.

Hertting et al. demonstrated that the first TCA, imipramine, inhibited cellular uptake of NA in peripheral tissues. Moreover, both antidepressant agents were demonstrated to prevent reserpine-induced sedation. Likewise, administration of DOPA to laboratory animals was shown to reverse reserpine induced sedation; a finding reproduced in humans. Amphetamine, which releases NA from vesicles and prevents re-uptake was also used in the treatment of depression at the time with varying success.

In 1965 Schildkraut formulated the catecholamine theory of depression. This was subsequently the most widely cited article in the American Journal of Psychiatry. The theory stated that “some, if not all, depressions are associated with an absolute or relative deficiency of catecholamines, in particular noradrenaline (NA), at functionally important adrenergic receptor sites in the brain. However, elation may be associated with an excess of such amines.”

Shortly after Schildkraut’s catecholamine hypothesis was published, Coppen proposed that 5-HT, rather than NA, was the more important neurotransmitter in depression. This was based on similar evidence to that which produced the NA theory as reserpine, imipramine, and iproniazid affect the 5-HT system, in addition to the noradrenergic system. It was also supported by work demonstrating that if catecholamine levels were depleted by up to 20% but 5-HT neurotransmission remained unaltered there was no sedation in animals. Alongside this, the main observation promoting the 5-HT theory was that administration of a MAOI in conjunction with tryptophan (precursor of 5-HT) elevated mood in control patients and potentiated the antidepressant effect of MAOI. Set against this, combination of an MAOI with DOPA did not produce a therapeutic benefit.

Inserting a chlorine atom into imipramine leads to clomipramine, a drug that is much more SERT selective than the parent compound.

Clomipramine was a predecessor to the development of the more recent SSRIs. There was, in fact, a time prior to the SSRIs when selective NRIs were being considered (c.f. talopram and melitracen). In fact, it is also believed that the selective NRI nisoxetine was discovered prior to the invention of fluoxetine. However, the selective NRIs did not get promoted in the same way as did the SSRIs, possibly due to an increased risk of suicide. This was accounted for on the basis of the energising effect that these agents have. Moreover, NRIs have the additional adverse safety risk of hypertension that is not seen for SSRIs. Nevertheless, NRIs have still found uses.

Further support for the monoamine hypothesis came from monoamine depletion studies:

  • Alpha-methyl-p-tyrosine (AMPT) is a tyrosine hydroxylase enzyme inhibitor that serves to inhibit catecholamine synthesis. AMPT led to a resurgence of depressive symptoms in patients improved by the NE reuptake inhibitor (NRI) desipramine, but not by the SSRI fluoxetine. The mood changes induced by AMPT may be mediated by decreases in norepinephrine, while changes in selective attention and motivation may be mediated by dopamine.
  • Dietary depletion of the DA precursors phenylalanine and tyrosine does not result in the relapse of formerly depressed patients off their medication.
  • Administration of fenclonine (para-chlorophenylalanine) is able to bring about a depletion of 5-HT. The mechanism of action for this is via tryptophan hydroxylase inhibition. In the 1970s administration of parachlorophenylalanine produced a relapse in depressive symptoms of treated patients, but it is considered too toxic for use today.
  • Although depletion of tryptophan — the rate-limiting factor of serotonin synthesis — does not influence the mood of healthy volunteers and untreated patients with depression, it does produce a rapid relapse of depressive symptoms in about 50% of remitted patients who are being, or have recently been treated with serotonin selective antidepressants.

Dopaminergic

There appears to be a pattern of symptoms that are currently inadequately addressed by serotonergic antidepressants — loss of pleasure (anhedonia), reduced motivation, loss of interest, fatigue and loss of energy, motor retardation, apathy and hypersomnia. Addition of a pro-dopaminergic component into a serotonin based therapy would be expected to address some of these short-comings.

Several lines of evidence suggest that an attenuated function of the dopaminergic system may play an important role in depression:

  • Mood disorders are highly prevalent in pathologies characterized by a deficit in central DA transmission such as Parkinson’s disease (PD). The prevalence of depression can reach up to 50% of individuals with PD.
  • Patients taking strong dopaminergic antagonists such as those used in the treatment of psychosis are more likely than the general population to develop symptoms of depression.
  • Data from clinical studies have shown that DA agonists, such as bromocriptine, pramipexole and ropinirole, exhibit antidepressant properties.
  • Amineptine, a TCA-derivative that predominantly inhibits DA re-uptake and has minimal noradrenergic and serotonergic activity has also been shown to possess antidepressant activity. A number of studies have suggested that amineptine has similar efficacy to the TCAs, MAOIs and SSRIs. However, amineptine is no longer available as a treatment for depression due to reports of an abuse potential.
  • The B-subtype selective MAOI selegiline (a drug developed for the treatment of PD) has now been approved for the treatment of depression in the form of a transdermal patch (Emsam). For some reason, there have been numerous reports of users taking this drug in conjunction with β-phenethylamine.
  • Taking psychostimulants for the alleviation of depression is well proven strategy, although in a clinical setting the use of such drugs is usually prohibited because of their strong addiction propensity.
  • When users withdraw from psychostimulant drugs of abuse (in particular, amphetamine), they experience symptoms of depression. This is likely because the brain enters into a hypodopaminergic state, although there might be a role for noradrenaline also.

For these drugs to be reinforcing, they must block more than 50% of the DAT within a relatively short time period (<15 minutes from administration) and clear the brain rapidly to enable fast repeated administration.

In addition to mood, they may also improve cognitive performance, although this remains to be demonstrated in humans.

The rate of clearance from the body is faster for ritalin than it is for regular amphetamine.

Noradrenergic

The decreased levels of NA proposed by Schildkraut, suggested that there would be a compensatory upregulation of β-adrenoceptors. Despite inconsistent findings supporting this, more consistent evidence demonstrates that chronic treatment with antidepressants and electroconvulsive therapy (ECT) decrease β-adrenoceptor density in the rat forebrain. This led to the theory that β-adrenoceptor downregulation was required for clinical antidepressant efficacy. However, some of the newly developed antidepressants do not alter, or even increase β-adrenoceptor density.

Another adrenoceptor implicated in depression is the presynaptic α2-adrenoceptor. Chronic desipramine treatment in rats decreased the sensitivity of α2-adrenoceptors, a finding supported by the fact that clonidine administration caused a significant increase in growth hormone (an indirect measure of α2-adrenoceptor activity) although platelet studies proved inconsistent. This supersensitivity of α2-adrenoceptor was postulated to decrease locus coeruleus (the main projection site of NA in the central nervous system, CNS) NA activity leading to depression.

In addition to enhancing NA release, α2-adrenoceptor antagonism also increases serotonergic neurotransmission due to blockade of α2-adrenoceptors present on 5-HT nerve terminals.

Serotonergic

5-Hydroxytryptamine (5-HT or serotonin) is an important cell-to-cell signalling molecule found in all animal phyla. In mammals, substantial concentrations of 5-HT are present in the central and peripheral nervous systems, gastrointestinal tract and cardiovascular system. 5-HT is capable of exerting a wide variety of biological effects by interacting with specific membrane-bound receptors, and at least 13 distinct 5-HT receptor subtypes have been cloned and characterised. With the exception of the 5-HT3 receptor subtype, which is a transmitter-gated ion channel, 5-HT receptors are members of the 7-transmembrane G protein-coupled receptor superfamily. In humans, the serotonergic system is implicated in various physiological processes such as sleep-wake cycles, maintenance of mood, control of food intake and regulation of blood pressure. In accordance with this, drugs that affect 5-HT-containing cells or 5-HT receptors are effective treatments for numerous indications, including depression, anxiety, obesity, nausea, and migraine.

Because serotonin and the related hormone melatonin are involved in promoting sleep, they counterbalance the wake-promoting action of increased catecholaminergic neurotransmission. This is accounted for by the lethargic feel that some SSRIs can produce, although TCAs and antipsychotics can also cause lethargy albeit through different mechanisms.

Appetite suppression is related to 5-HT2C receptor activation as for example was reported for PAL-287 recently.

Activation of the 5-HT2C receptor has been described as “panicogen” by users of ligands for this receptor (e.g. mCPP). Antagonism of the 5-HT2C receptor is known to augment dopaminergic output. Although SSRIs with 5-HT2C antagonist actions were recommended for the treatment of depression, 5-HT2C receptor agonists were suggested for treating cocaine addiction since this would be anti-addictive. Nevertheless, the 5-HT2C is known to be rapidly downregulated upon repeated administration of an agonist agent, and is actually antagonised.

Azapirone-type drugs (e.g. buspirone), which act as 5-HT1A receptor agonists and partial agonists have been developed as anxiolytic agents that are not associated with the dependence and side-effect profile of the benzodiazepines. The hippocampal neurogenesis produced by various types of antidepressants, likewise, is thought to be mediated by 5-HT1A receptors. Systemic administration of a 5-HT1A agonist also induces growth hormone and adrenocorticotropic hormone (ACTH) release through actions in the hypothalamus.

Current Antidepressants

Most antidepressants on the market today target the monoaminergic system.

SSRIs

The most commonly prescribed class of antidepressants in the USA today are the selective serotonin reuptake inhibitors (SSRIs). These drugs inhibit the uptake of the neurotransmitter 5-HT by blocking the SERT, thus increasing its synaptic concentration, and have shown to be efficacious in the treatment of depression, however sexual dysfunction and weight gain are two very common side-effects that result in discontinuation of treatment.

Although many patients benefit from SSRIs, it is estimated that approximately 50% of depressive individuals do not respond adequately to these agents. Even in remitters, a relapse is often observed following drug discontinuation. The major limitation of SSRIs concerns their delay of action. It appears that the clinical efficacy of SSRIs becomes evident only after a few weeks.

SSRIs can be combined with a host of other drugs including bupropion, α2 adrenergic antagonists (e.g. yohimbine) as well as some of the atypical antipsychotics. The augmentation agents are said to behave synergistically with the SSRI although these are clearly of less value than taking a single compound that contains all of the necessary pharmacophoric elements relative to the consumption of a mixture of different compounds. It is not entirely known what the reason for this is, although ease of dosing is likely to be a considerable factor. In addition, single compounds are more likely to be approved by the FDA than are drugs that contain greater than one pharmaceutical ingredient (polytherapies).

A number of SRIs were under development that had auxiliary interactions with other receptors. Particularly notable were agents behaving as co-joint SSRIs with additional antagonist activity at 5-HT1A receptors. 5-HT1A receptors are located presynaptically as well as post-synaptically. It is the presynaptic receptors that are believed to function as autoreceptors (cf. studies done with pindolol). These agents were shown to elicit a more robust augmentation in the % elevation of extracellular 5-HT relative to baseline than was the case for SSRIs as measured by in vivo microdialysis.

NRIs

Norepinephrine reuptake inhibitors (NRIs) such as reboxetine prevent the reuptake of norepinephrine, providing a different mechanism of action to treat depression. However reboxetine is no more effective than the SSRIs in treating depression. In addition, atomoxetine has found use in the treatment of ADHD as a non-addictive alternative to Ritalin. The chemical structure of atomoxetine is closely related to that of fluoxetine (an SSRI) and also duloxetine (an SNRI).

NDRIs

Bupropion is a commonly prescribed antidepressant that acts as a norepinephrine–dopamine reuptake inhibitor (NDRI). It prevents the reuptake of NA and DA (weakly) by blocking the corresponding transporters, leading to increased noradrenergic and dopaminergic neurotransmission. This drug does not cause sexual dysfunction or weight gain like the SSRIs but has a higher incidence of nausea. Methylphenidate is a much more reliable example of an NDRI (the action that it displays on the DAT usually getting preferential treatment). Methylphenidate is used in the treatment of ADHD; its use in treating depression is not known to have been reported, but it is presumed owing to its psychomotor activating effects and it functioning as a positive reinforcer. There are also reports of methylphenidate being used in the treatment of psychostimulant addiction, in particular cocaine addiction, since the addictive actions of this drug are believed to be mediated by the dopamine neurotransmitter.

SNRIs

Serotonin–norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor), its active metabolite desvenlafaxine (Pristiq), and duloxetine (Cymbalta) prevent the reuptake of both serotonin and norepinephrine, however their efficacy appears to be only marginally greater than the SSRIs.

Sibutramine is the name of an SNRI based appetite suppressant with use in the treatment of obesity. This was explored in the treatment of depression, but was shown not to be effective.

Both sibutramine and venlafaxine are phenethylamine-based. At high doses, both venlafaxine and sibutramine will start producing dopaminergic effects. The inhibition of DA reuptake is unlikely to be relevant at clinically approved doses.

MAOIs

Monoamine oxidase inhibitors (MAOIs) were the first antidepressants to be introduced. They were discovered entirely by serendipity. Iproniazide (the first MAOI) was originally developed as an antitubercular agent but was then unexpectedly found to display antidepressant activity.

Isoniazid also displayed activity as an antidepressant, even though it is not a MAOI. This led some people to question whether it is some property of the hydrazine, which is responsible for mediating the antidepressant effect, even going as far as to state that the MAOI activity could be a secondary side-effect. However, with the discovery of tranylcypromine (the first non-hydrazine MAOI), it was shown that MAOI is thought to underlie the antidepressant bioactivity of these agents. Etryptamine is another example of a non-hydrazine MAOI that was introduced.

The MAOIs work by inhibiting the monoamine oxidase enzymes that, as the name suggests, break down the monoamine neurotransmitters. This leads to increased concentrations of most of the monoamine neurotransmitters in the human brain, serotonin, norepinephrine, dopamine and melatonin. The fact that they are more efficacious than the newer generation antidepressants is what leads scientists to develop newer antidepressants that target a greater range of neurotransmitters. The problem with MAOIs is that they have many potentially dangerous side-effects such as hypotension, and there is a risk of food and drug interactions that can result in potentially fatal serotonin syndrome or a hypertensive crisis. Although selective MAOIs can reduce, if not eliminate these risks, their efficacy tends to be lower.

MAOIs may preferentially treat TCA-resistant depression, especially in patients with features such as fatigue, volition inhibition, motor retardation and hypersomnia. This may be a function of the ability of MAOIs to increase synaptic levels of DA in addition to 5-HT and NE. The MAOIs also seem to be effective in the treatment of fatigue associated with fibromyalgia (FM) or chronic fatigue syndrome (CFS).

Although a substantial number of MAOIs were approved in the 1960s, many of these were taken off the market as rapidly as they were introduced. The reason for this is that they were hepatotoxic and could cause jaundice.

TCAs

The first tricyclic antidepressant (TCA), imipramine (Tofranil), was derived from the antipsychotic drug chlorpromazine, which was developed as a useful antihistaminergic agent with possible use as a hypnotic sedative. Imipramine is an iminodibenzyl (dibenzazepine).

The TCAs such as imipramine and amitriptyline typically prevent the reuptake of serotonin or norepinephine.

It is the histaminiergic (H1), muscarinic acetylcholinergic (M1), and alpha adrenergic (α1) blockade that is responsible for the side-effects of TCAs. These include somnolence and lethargy, anticholinergic side-effects, and hypotension. Due to the narrow gap between their ability to block the biogenic amine uptake pumps versus the inhibition of fast sodium channels, even a modest overdose of one of the TCAs could be lethal. TCAs were, for 25 years, the leading cause of death from overdoses in many countries. Patients being treated with antidepressants are prone to attempt suicide and one method they use is to take an overdose of their medications.

Another example of a TCA is amineptine which is the only one believed to function as a DRI. It is no longer available.

Failure of SNDRIs for Depression

SNDRIs have been under investigation for the treatment of major depressive disorder for a number of years but, as of 2015, have failed to meet effectiveness expectations in clinical trials. In addition, the augmentation of a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor with lisdexamfetamine, a norepinephrine–dopamine releasing agent, recently failed to separate from placebo in phase III clinical trials of individuals with treatment-resistant depression, and clinical development was subsequently discontinued. These occurrences have shed doubt on the potential benefit of dopaminergic augmentation of conventional serotonergic and noradrenergic antidepressant therapy. As such, scepticism has been cast on the promise of the remaining SNDRIs that are still being trialled, such as ansofaxine (currently in phase II trials), in the treatment of depression. Despite being a weak SNDRI, nefazodone has been successful in treating major depressive disorder.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Serotonin%E2%80%93norepinephrine%E2%80%93dopamine_reuptake_inhibitor >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Schema Therapy?

Published on by Andrew Marshall2 Comments

Introduction

Schema therapy was developed by Jeffrey E. Young for use in treatment of personality disorders and chronic DSM Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies (for example, traditional cognitive behavioural therapy (CBT)). Schema therapy is an integrative psychotherapy combining theory and techniques from previously existing therapies, including CBT, psychoanalytic object relations theory, attachment theory, and Gestalt therapy.

Background

Four main theoretical concepts in schema therapy are early maladaptive schemas (or simply schemas), coping styles, modes, and basic emotional needs:

  1. In cognitive psychology, a schema is an organised pattern of thought and behaviour. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. In schema therapy, a schema specifically refers to an early maladaptive schema, defined as a pervasive self-defeating or dysfunctional theme or pattern of memories, emotions, and physical sensations, developed during childhood or adolescence and elaborated throughout one’s lifetime. Often they have the form of a belief about the self or the world. For instance, a person with an Abandonment schema could be hypersensitive (have an “emotional button” or “trigger”) about their perceived value to others, which in turn could make them feel sad and panicky in their interpersonal relationships.
  2. Coping styles are a person’s behavioural responses to schemas. There are three potential coping styles. In “avoidance” the person tries to avoid situations that activate the schema. In “surrender” the person gives into the schema, doesn’t try to fight against it, and changes their behavior in expectation that the feared outcome is inevitable. In “counterattack”, also called “overcompensation”, the person puts extra work into not allowing the schema’s feared outcome to happen. These maladaptive coping styles (overcompensation, avoidance, or surrender) very often wind up reinforcing the schemas. Continuing the Abandonment example: having imagined a threat of abandonment in a relationship and feeling sad and panicky, a person using an avoidance coping style might then behave in ways to limit the closeness in the relationship to try to protect themself from being abandoned. The resulting loneliness or even actual loss of the relationship could easily reinforce the person’s Abandonment schema. Another example can be given for the Defectiveness schema: A person using an avoidance coping style might avoid situations that make them feel defective, or might try to numb the feeling with addictions or distractions. A person using a surrender coping style might tolerate unfair criticism without defending themself. A person using the counterattack/overcompensation coping style might put extra effort into being superhuman.
  3. Modes are mind states that cluster schemas and coping styles into a temporary “way of being” that a person can shift into occasionally or more frequently. For example, a Vulnerable Child mode might be a state of mind encompassing schemas of Abandonment, Defectiveness, Mistrust/Abuse and a coping style of surrendering (to the schemas).
  4. If a patient’s basic emotional needs are not met in childhood, then schemas, coping styles, and modes can develop. Some basic needs that have been identified are: connection, mutuality, reciprocity, flow, and autonomy. For example, a child with unmet needs around connection—perhaps due to parental loss to death, divorce, or addiction—might develop an Abandonment schema.

The goal of schema therapy is to help patients meet their basic emotional needs by helping the patient learn how to:

  • Heal schemas by diminishing the intensity of emotional memories comprising the schema and the intensity of bodily sensations, and by changing the cognitive patterns connected to the schema; and
  • Replace maladaptive coping styles and responses with adaptive patterns of behaviour.

Techniques used in schema therapy including limited reparenting and Gestalt therapy psychodrama techniques such as imagery re-scripting and empty chair dialogues. See § Techniques in schema therapy, below.

Early Maladaptive Schemas

Early maladaptive schemas are self-defeating emotional and cognitive patterns established from childhood and repeated throughout life. They may be made up of emotional memories of past hurt, tragedy, fear, abuse, neglect, unmet safety needs, abandonment, or lack of normal human affection in general. Early maladaptive schemas can also include bodily sensations associated with such emotional memories. Early maladaptive schemas can have different levels of severity and pervasiveness: the more severe the schema, the more intense the negative emotion when the schema is triggered and the longer it lasts; the more pervasive the schema, the greater the number of situations that trigger it.

Schema Domains

Schema domains are five broad categories of unmet needs into which are grouped 18 early maladaptive schemas identified by Young, Klosko & Weishaar (2003):

  1. Disconnection/Rejection includes 5 schemas:
    • Abandonment/Instability
    • Mistrust/Abuse
    • Emotional Deprivation
    • Defectiveness/Shame
    • Social Isolation/Alienation
  2. Impaired Autonomy and/or Performance includes 4 schemas:
    • Dependence/Incompetence
    • Vulnerability to Harm or Illness
    • Enmeshment/Undeveloped Self
    • Failure
  3. Impaired Limits includes 2 schemas:
    • Entitlement/Grandiosity
    • Insufficient Self-Control and/or Self-Discipline
  4. Other-Directedness includes 3 schemas:
    • Subjugation
    • Self-Sacrifice
    • Approval-Seeking/Recognition-Seeking
  5. Overvigilance/Inhibition includes 4 schemas:
    • Negativity/Pessimism
    • Emotional Inhibition
    • Unrelenting Standards/Hypercriticalness
    • Punitiveness

Yalcin, Lee & Correia (2020) did a primary and a higher-order factor analysis of data from a large clinical sample and smaller non-clinical population. The higher-order factor analysis indicated four schema domains—Emotional Dysregulation, Disconnection, Impaired Autonomy/Underdeveloped Self, and Excessive Responsibility/Overcontrol—that overlap with the five domains (listed above) proposed earlier by Young, Klosko & Weishaar (2003). The primary factor analysis indicated that the Emotional Inhibition schema could be split into Emotional Constriction and Fear of Losing Control, and the Punitiveness schema could be split into Punitiveness (Self) and Punitiveness (Other).

Schema Modes

Schema modes are momentary mind states which every human being experiences at one time or another. A schema mode consists of a cluster of schemas and coping styles. Life situations that a person finds disturbing or offensive, or arouse bad memories, are referred to as “triggers” that tend to activate schema modes. In psychologically healthy persons, schema modes are mild, flexible mind states that are easily pacified by the rest of their personality. In patients with personality disorders, schema modes are more severe, rigid mind states that may seem split off from the rest of their personality.

Identified Schema Modes

Young, Klosko & Weishaar (2003) identified 10 schema modes, further described by Jacob, Genderen & Seebauer (2015), and grouped into four categories. The four categories are: Child modes, Dysfunctional Coping modes, Dysfunctional Parent modes, and the Healthy Adult mode. The four Child modes are: Vulnerable Child, Angry Child, Impulsive/Undisciplined Child, and Happy Child. The three Dysfunctional Coping modes are: Compliant Surrenderer, Detached Protector, and Overcompensator. The two Dysfunctional Parent modes are: Punitive Parent and Demanding Parent.

  • Vulnerable Child is the mode in which a patient may feel defective in some way, thrown aside, unloved, obviously alone, or may be in a “me against the world” mindset. The patient may feel as though peers, friends, family, and even the entire world have abandoned them. Behaviours of patients in Vulnerable Child mode may include (but are not limited to) falling into major depression, pessimism, feeling unwanted, feeling unworthy of love, and perceiving personality traits as irredeemable flaws. Rarely, a patient’s self-perceived flaws may be intentionally withheld on the inside; when this occurs, instead of showing one’s true self, the patient may appear to others as “egotistical”, “attention-seeking”, selfish, distant, and may exhibit behaviours unlike their true nature. The patient might create a narcissistic alter-ego/persona in order to escape or hide the insecurity from others. Due to fear of rejection, of feeling disconnected from their true self and poor self-image, these patients, who truly desire companionship/affection, may instead end up pushing others away.
  • Angry Child is fuelled mainly by feelings of victimization or bitterness, leading towards negativity, pessimism, jealousy, and rage. While experiencing this schema mode, a patient may have urges to yell, scream, throw/break things, or possibly even injure themself or harm others. The Angry Child schema mode is enraged, anxious, frustrated, self-doubting, feels unsupported in ideas and vulnerable.
  • Impulsive Child is the mode where anything goes. Behaviours of the Impulsive Child schema mode may include reckless driving, substance abuse, cutting oneself, suicidal thoughts, gambling, or fits of rage, such as punching a wall when “triggered” or laying blame of circumstantial difficulties upon innocent people. Unsafe sex, rash decisions to run away from a situation without resolution, tantrums perceived by peers as infantile, and so forth are a mere few of the behaviours which a patient in this schema mode might display. Impulsive Child is the rebellious and careless schema mode.
  • Happy Child occurs when one feels like their needs are being met. When people experience the Happy Child mode, they feel safe, loved, and content. They experience a joyful sense of wonder and playfulness about the world. This mode is healthy as it represents the absence of activation of maladaptive schemas. While healthy adults spend most of their time in the Healthy Adult mode, they also cultivate their Happy Child to balance the demands of life with a sense of lightheartedness.
  • Compliant Surrenderer is a coping mode where one experiences the schema that triggered it as true. This in turn leads to feelings such as helplessness, sadness, guilt, or anger about the situation. People in this mode often believe it is pointless to challenge their schema, and that it must simply be accepted. They also often adopt an interpersonally passive and dependent style, seeking to please people in their lives, to minimize conflict, and therefore avoid further harm or abuse.
  • Detached Protector is based in escape. Patients in Detached Protector schema mode withdraw, dissociate, alienate, or hide in some way. This may be triggered by numerous stress factors or feelings of being overwhelmed. When a patient with insufficient skills is in a situation involving excessive demands, it can trigger a Detached Protector response mode. Stated simply, patients become numb in order to protect themselves from the harm or stress of what they fear is to come, or to protect themselves from fear of the unknown in general.
  • Overcompensator is marked by attempts to fight off schemas in a way that is rigid and extreme. It often involves aggressiveness, rebelliousness, violating the rights of other people, and an attempt to dominate them. In this mode, a person who feels emotionally deprived demands affection from others, while a person who believes others cannot be trusted will try to preemptively hurt them before they do. It may also involve obsessiveness in an excessive attempt to control the environment, or forced behaviors, such as extreme forgiveness for someone with a Punitiveness schema.
  • Punitive Parent is identified by beliefs of a patient that they should be harshly punished, perhaps due to feeling “defective”, or making a simple mistake. The patient may feel that they should be punished for even existing. Sadness, anger, impatience, and judgment are directed to the patient and from the patient. The Punitive Parent has great difficulty in forgiving themself even under average circumstances in which anyone could fall short of their standards. The Punitive Parent does not wish to allow for human error or imperfection, thus punishment is what this mode seeks.
  • Demanding Parent is associated with a strong sense of pressure to achieve. When experiencing this mode, people often feel like their performance is inadequate, no matter how well they do or how much effort they make. Common beliefs also involve the idea that rest, fun, and relaxation are not acceptable and that one’s attention should remain focused on achieving more. It is important to note that while this mode is often accompanied by Punitive Parent, this is not always the case. Clients with the Demanding Parent mode feel pressure and dissatisfaction with their achievements, but not necessarily guilt, shame or feelings of worthlessness.
  • Healthy Adult is the mode that schema therapy aims to help a patient achieve as the long-lasting state of well-being. The Healthy Adult is comfortable making decisions, is a problem-solver, thinks before acting, is appropriately ambitious, sets limits and boundaries, nurtures self and others, forms healthy relationships, takes on all responsibility, sees things through, and enjoys/partakes in enjoyable adult activities and interests with boundaries enforced, takes care of their physical health, and values themself. In this schema mode the patient focuses on the present day with hope and strives toward the best tomorrow possible. The Healthy Adult forgives the past, no longer sees themself as a victim (but as a survivor), and expresses all emotions in ways which are healthy and cause no harm.

Techniques in Schema Therapy

Treatment plans in schema therapy generally encompass three basic classes of techniques: cognitive, experiential, and behavioural (in addition to the basic healing components of the therapeutic relationship). Cognitive strategies expand on standard cognitive behavioural therapy techniques such as listing pros and cons of a schema, testing the validity of a schema, or conducting a dialogue between the “schema side” and the “healthy side”. Experiential and emotion focused strategies expand on standard Gestalt therapy psychodrama and imagery techniques. Behavioural pattern-breaking strategies expand on standard behaviour therapy techniques, such as role playing an interaction and then assigning the interaction as homework. One of the most central techniques in schema therapy is the use of the therapeutic relationship, specifically through a process called “limited reparenting”.

Specific techniques often used in schema therapy include flash cards with important therapeutic messages, created in session and used by the patient between sessions, and the schema diary – a template or workbook that is filled out by the patient between sessions and that records the patient’s progress in relation to all the theoretical concepts in schema therapy.

Schema Therapy and Psychoanalysis

From an integrative psychotherapy perspective, limited reparenting and the experiential techniques, particularly around changing modes, could be seen as actively changing what psychoanalysis has described as object relations. Historically, mainstream psychoanalysis tended to reject active techniques—such as Fritz Perls’ Gestalt therapy work or Franz Alexander’s “corrective emotional experience” – but contemporary relational psychoanalysis (led by analysts such as Lewis Aron, and building on the ideas of earlier unorthodox analysts such as Sándor Ferenczi) is more open to active techniques. It is notable that in a head-to-head comparison of a psychoanalytic object relations treatment (Otto F. Kernberg’s transference focused psychotherapy) and schema therapy, the latter has been demonstrated to be more effective in treating Borderline Personality Disorder.

Outcome Studies on Schema Therapy

Schema Therapy vs Transference Focused Psychotherapy Outcomes

Dutch investigators, including Josephine Giesen-Bloo and Arnoud Arntz (the project leader), compared schema therapy (also known as schema focused therapy or SFT) with transference focused psychotherapy (TFP) in the treatment of borderline personality disorder. 86 patients were recruited from four mental health institutes in the Netherlands. Patients in the study received two sessions per week of SFT or TFP for three years. After three years, full recovery was achieved in 45% of the patients in the SFT condition, and in 24% of those receiving TFP. One year later, the percentage fully recovered increased to 52% in the SFT condition and 29% in the TFP condition, with 70% of the patients in the SFT group achieving “clinically significant and relevant improvement”. Moreover, the dropout rate was only 27% for SFT, compared with 50% for TFP.

Patients began to feel and function significantly better after the first year, with improvement occurring more rapidly in the SFT group. There was continuing improvement in subsequent years. Thus investigators concluded that both treatments had positive effects, with schema therapy clearly more successful.

Less Intensive Outpatient, Individual Schema Therapy

Dutch investigators, including Marjon Nadort and Arnoud Arntz, assessed the effectiveness of schema therapy in the treatment of borderline personality disorder when utilised in regular mental health care settings. A total of 62 patients were treated in eight mental health centres located in the Netherlands. The treatment was less intensive along a number of dimensions including a shift from twice weekly to once weekly sessions during the second year. Despite this, there was no lessening of effectiveness with recovery rates that were at least as high and similarly low dropout rates.

Pilot Study of Group Schema Therapy for Borderline Personality Disorder

Investigators Joan Farrell, Ida Shaw and Michael Webber at the Indiana University School of Medicine Centre for BPD Treatment & Research tested the effectiveness of adding an eight-month, 30-session schema therapy group to treatment-as-usual (TAU) for borderline personality disorder (BPD) with 32 patients. The dropout rate was 0% for those patients who received group schema therapy in addition to TAU and 25% for those who received TAU alone. At the end of treatment, 94% of the patients who received group schema therapy in addition to TAU compared to 16% of the patients receiving TAU alone no longer met BPD diagnostic criteria. The schema therapy group treatment led to significant reductions in symptoms and global improvement in functioning. The large positive treatment effects found in the group schema therapy study suggest that the group modality may augment or catalyse the active ingredients of the treatment for BPD patients. As of 2014, a collaborative randomised controlled trial is under way at 14 sites in six countries to further explore this interaction between groups and schema therapy.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Schema_therapy >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Compassion-Focused Therapy?

Published on by Andrew Marshall1 Comment

Introduction

Compassion Focused Therapy (CFT) is a system of psychotherapy developed by Professor Paul Gilbert (OBE) that integrates techniques from cognitive behavioural therapy (CBT) with concepts from evolutionary psychology, social psychology, developmental psychology, Buddhist psychology, and neuroscience. According to Gilbert, “One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion.”

Overview

A central therapeutic technique of CFT is compassionate mind training, which teaches the skills and attributes of compassion. Compassionate mind training helps transform problematic patterns of cognition and emotion related to anxiety, anger, shame and self-criticism.

Biological evolution forms the theoretical backbone of CFT. Humans have evolved with at least three primal types of emotion regulation system: the threat (protection) system, the drive (resource-seeking) system, and the soothing system. CFT emphasizes the links between cognitive patterns and these three emotion regulation systems. Through the use of techniques such as compassionate mind training and CBT, counselling clients can learn to manage each system more effectively and respond more appropriately to situations.

Compassion Focused Therapy is especially appropriate for people who have high levels of shame and self-criticism and who have difficulty in feeling warmth toward, and being kind to, themselves or others. CFT can help such people learn to feel more safeness and warmth in their interactions with others and themselves.

Numerous methods are used in CFT to develop a person’s compassion. For example, people undergoing CFT are taught to understand compassion from the third person, before transferring these thought processes to themselves. 

Core Principles

CFT is largely built on the idea that the evolution of caring behaviour has major regulatory and developmental functions. The central focus of CFT is to concentrate on helping clients relate to their difficulties in compassionate ways, as well as provide them with effective tools to work with challenging circumstances and emotions they encounter. CFT helps those learn tools to engage with their battles in accepting and encouraging ways, thereby aiding themselves to feel confident about accomplishing difficult tasks and dealing with challenging situations.

This is facilitated by:

  • Developing a positive therapeutic relationship that facilitates the process of engaging with one’s challenges and development of skills to deal with them.
  • Developing non-blaming compassionate understandings into the nature of suffering.
  • Developing the ability to experience and cultivate compassionate attributes.
  • Developing the feeling of compassion for others, being open to compassion from others, and developing self-compassion.

According to evolutionary analysis, there are three types of functional emotion regulation systems:

  • Drive;
  • Safety; and
  • Threat.

CFT is based on the relationship and interactions between these systems. One is born with each system but our surroundings implicate whether one utilises and sustains the non-survival-based systems (drive and caregiving).

  • Threat and self-protection focused system: evolved to alert and direct attention to detect and respond to threats. This system contains threat-based emotions (anger, anxiety, disgust), and threat-based behaviours (fight/flight, freezing).
  • Drive, seeking and acquisition focused system: pay attention and notice advantageous resources, experience drive and pleasure in securing them (positive system is activating).
  • Contentment, soothing and affiliative system: enables state of peacefulness when individuals are no longer focused on threats or seeking out resources (allows body to rest and digest and have open attention).

Using CFT enriches the compassion-based soothing system, while withdrawing from the threat-focused emotional regulation system. In turn, this will augment the ability to activate (drive) and work towards valued goals.

Applications

CFT has been investigated as a novel treatment for a wide variety of psychological disorders. A 2012 randomised controlled trial showed CFT to be a safe and clinically effective treatment option for psychosis patients. CFT was shown to be more effective than “treatment as usual”, with particular efficacy in reducing depression symptoms. A further 2015 literature review of 14 different studies showed promising psychotherapeutic benefits of CFT, especially when treating mood disorders. A recent meta analysis found good support for CFT as a treatment for a variety of psychological difficulties. However, further large-scale trials are necessary in order for CFT to become an accepted, “evidence-based” treatment for these disorders.

CFT has also been explored as a treatment for individuals with eating disorders. This slightly modified version of CFT, CFT-E, has had promising results in treating adult outpatients with restrictive eating disorders as well as with binging and purging disorders. A 2014 literature review found CFT-E to be a particularly effective treatment for eating disorders due to the fact that it confronts the “high levels of shame and self‐criticism” that patients often experience. More recent primary studies have further proved CFT-E to be a safe and effective intervention for eating disorders.

CFT is also being studied as a rehabilitation method for patients with acquired brain injuries (ABI). Preliminary, small-scale studies have shown CFT to be safe and beneficial in treating anxiety and depressive symptoms of ABI patients, although further large-scale studies are needed.

As well as being a psychological therapy (for individuals and groups), Compassionate Mind Training (CMT) has been shown to be an effective approach for reducing psychological distress in the general public. A variety of studies have found that engaging in guided audios, online courses, an 8 week group and using an app (The Self-Compassion App) can lead to reductions in self-criticism, shame, attachment insecurity, depression and anxiety symptoms, as well as increasing self-compassion, positive emotions and wellbeing.

CMT has also been used as an effective approach in schools, with results suggesting a variety of benefits for teachers who engaged in an 8 week compassion training course.

Limitations

Beaumont and Hollins Martin (2015) examined narrative reviews of 12 research findings that has shown use of CFT to treat and experiment with psychological outcomes in clinical populations. The researchers found that overall, there are improvements of mental health issues with CFT intervention, especially when combined with approaches such as CBT.

Beaumont and Hollins Martin (2015) found a major limitation in the empirical studies are the small number of participants involved in each case. For instance, Gilbert and Proctor (2006) showed small reductions in depression, anxiety, self-criticism and shame, however their participant group involved only 6 members. The small number of participants can cause bias or facilitate a problem of generalisation for the broader population. For instance, out of the twelve studies only two individually supported effectiveness of CFT. A study conducted by Lucre and Corten (2012) found CFT to be effective for treating patients with personality disorders, and another study by Heriot-Maitland et al. (2014) found that treating clients in acute inpatient settings was effective.

Recommendations

The findings of Beaumont and Hollins Martin (2015) recommended that the effectiveness of CFT needs further extensive research in order to fully examine reductions in mental illnesses and overall improvements in quality of life. This study recommends for consideration of larger samples of participants in order to ensure that CFT can be independently effective without other psychotherapy interventions involved such as CBT.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Compassion-focused_therapy >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Attachment-Based Psychotherapy?

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Introduction

Attachment-based psychotherapy is a psychoanalytic psychotherapy that is informed by attachment theory.

Attachment-based psychotherapy combines the epidemiological categories of attachment theory (including the identification of the attachment styles such as secure, anxious, ambivalent and disorganised/disoriented) with an analysis and understanding of how dysfunctional attachments get represented in the human inner world and subsequently re-enacted in adult life. Attachment-based psychotherapy is the framework of treating individuals with depression, anxiety, and childhood trauma. Psychotherapy, or talk therapy, can help to alleviate dysfunctional emotions caused by attachment disorders, such as jealousy, rage, rejection, loss, and commitment issues that are brought on by the lack of response from a parent or the loss of a loved one. Events, such as domestic abuse or lack of a parental figure, can result in these dysfunctional emotions. These issues can also have effects of the child in their adulthood, by making them incapable of making and keeping healthy relationships or by making them have false beliefs that they will be abandoned. The use of psychotherapy helps modify dysfunctional emotions in order to give the patient a healthy understanding of the traumatic experiences they have gone through. It is important for psychotherapists dealing with Attachment disorders to create a personal relationship with the patient in order to help the patient to make intimate attachments in their normal lives. Effective psychotherapy for patients dealing with attachment disorders must be supportive and consist of effective communication between the patient and therapist. Child attachment trauma leads into attachment issues as an adult. Individuals with attachment problems may show signs of distress during difficult situations, have trouble caring for others and letting themselves be cared for, are easily angered, and have difficulty focusing.

When an individual does not have security in their relationships, they rely on themselves and their emotions, resulting in unhealthy behaviour and cognitive functioning.

Treatment

Therapists apply psychotherapy to patients with attachment disorders by applying a method of listening and reflecting on the experiences of the patient that caused their difficulty in making emotional connections. The primary treatment for a child with attachment-based trauma is having a reliable caregiver. The next most important treatment is having a psychotherapist. The therapist’s objective is to get the patient to open up to them so the patient can explore the experiences that are causing them to have dysfunctional relationships and to recreate the experience from the point of view of the therapist in order to resolve any emotional or social disruptions within the patient’s life. According to Dan Hughes this process is known as “attunement, disruption, and repair”. The first part of the treatment, the attunement, consists of the forging of a personal relationship between the therapist and the patient, it is the first step for the patient toward creating healthy attachments. Attachment patients live stressful lives with very little emotional attachments to people, thus it is the therapist’s job to create a secure, accepting, caring, non-judgemental, and reliable environment where the patient can feel comfortable sharing their most traumatic experiences.

Once the patient and therapist have created a trust worthy and reliable relationship the therapist will probe the patient on any traumatic experiences that may have happened to them in their childhood and that connect to any disruptions in their lives at the time. The therapist pays special attention to the relationship between the patient and their parents because the lack of responsiveness of a parent early in a child development can lead to dysfunctional relationships later on in their life. The therapist may even ask the parent or caregiver to attend the therapy sessions in order to correct any complications in their relationship. The therapist will ask the parent to be present if they want to help the child and parent repair their relationship. The therapist will facilitate in their communication and have them share in an “affective/reflective” way. Having the parent in the room, such as in group therapy, may also help the patient face the root of their problems, which most psychologists believe stems from the parents. In this sense the parent or care giver will be taking on the role of the therapist in order to resolve issue that directly impact the parent’s life.  This part of the therapy treatment is called disruptive because by having the patients talk about their traumatic experiences and relationship with their parents in depth, the therapist is getting them to re-experience the trauma. Getting the patient to face their own trauma has the effect of getting them to accept their own ego and understand why they have trouble creating healthy attachments with people. As the patient shares their experiences the therapist is expected to be actively listening and express empathy and acceptance to the patient. The therapist creates an even deeper relationship with the patient by treating the patient’s experiences as their own experiences and coming up with their own interpretations to the events while constantly be understanding of and engaged with the patient. The therapist may also mimic the patient’s emotions in order to show their understanding and to encourage the patient to keep sharing.

After the patient shares the traumatic events from their life and the therapist integrates them as their own, the therapist begins the repair of the patient. The repair stage of the therapy aims to alter the patient’s current reactions to the events that cause them emotional distress by sharing their own interpretations of the event. By sharing their own subjective interpretation they hope create a new reality of the traumatic events for the patient in order to get rid of unwanted emotions.

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What is Emotionally Focused Therapy?

Published on by Andrew Marshall1 Comment

Introduction

Emotionally focused therapy and emotion-focused therapy (EFT) are related humanistic approaches to psychotherapy that aim to resolve emotional and relationship issues with individuals, couples, and families. These therapies combine experiential therapy techniques, including person-centred and Gestalt therapies, with systemic therapy and attachment theory. The central premise is that emotions influence cognition, motivate behaviour, and are strongly linked to needs. The goals of treatment include transforming maladaptive behaviours, such as emotional avoidance, and developing awareness, acceptance, expression, and regulation of emotion and understanding of relationships. EFT is usually a short-term treatment (eight to 20 sessions).

Emotion-focused therapy for individuals was originally known as process-experiential therapy, and continues to be referred to by this name in some contexts. EFT should not be confused with emotion-focused coping, a separate concept involving coping strategies for managing emotions. EFT has been used to improve clients’ emotion-focused coping abilities.

Brief History

EFT began in the mid-1980s as an approach to helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985, and the first manual for emotionally focused couples therapy was published in 1988.

To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behaviour. Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behaviour cannot be considered outside of the whole situation in which they occur. In this “experiential–systemic” approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners. Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organizes the interactions between partners.

In 1986, Greenberg chose “to refocus his efforts on developing and studying an experiential approach to individual therapy”. Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy. They attended to emotional experiencing and its role in individual self-organisation. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, providing detailed manuals of specific principles and methods of therapeutic intervention. Goldman & Greenberg (2015) presented case formulation maps for this approach.

Johnson continued to develop EFT for couples, integrating attachment theory with systemic and humanistic approaches, and explicitly expanding attachment theory’s understanding of love relationships. Johnson’s model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion (refer to Stages and Steps below). Johnson’s goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.

Greenberg & Goldman (2008) developed a variation of EFT for couples that contains some elements from Greenberg and Johnson’s original formulation but adds several steps and stages. Greenberg and Goldman posit three motivational dimensions:

  • (1) Attachment;
  • (2) Identity or power; and
  • (3) Attraction or liking—that impact emotion regulation in intimate relationships.

Similar Terminology, Different Meanings

The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists.

In Les Greenberg’s approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg “decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches.” He and colleague Rhonda Goldman noted their choice to “use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg’s and Johnson’s backgrounds) emotionally focused.” Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy. He considers the focus on emotions to be a common factor among various systems of psychotherapy:

“The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic.”

Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:

In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations. Furthermore, clinicians of different orientations recognised that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.

Sue Johnson’s use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation. Johnson views attachment needs as a primary motivational system for mammalian survival; her approach to EFT focuses on attachment theory as a theory of adult love wherein attachment, care-giving, and sex are intertwined. Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, love-ability and desire. Johnson’s approach to EFT aims to reshape attachment strategies towards optimal inter-dependency and emotion regulation, for resilience and physical, emotional, and relational health.

Features

Experiential Focus

All EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They all focus upon the value of engaging clients in emotional experiencing moment-to-moment in session. Thus, an experiential focus is prominent in all EFT approaches. All EFT theorists have expressed the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.

The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of all EFT approaches since their inception. EFT approaches value emotion as the target and agent of change, honouring the intersection of emotion, cognition, and behaviour. EFT approaches posit that emotion is the first, often subconscious response to experience. All EFT approaches also use the framework of primary and secondary (reactive) emotion responses.

Maladaptive Emotion Responses and Negative Patterns of Interaction

Greenberg and some other EFT theorists have categorized emotion responses into four types (see § Emotion response types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental. Greenberg has posited six principles of emotion processing:

  • (1) Awareness of emotion or naming what one feels;
  • (2) emotional expression;
  • (3) Regulation of emotion;
  • (4) Reflection on experience;
  • (5) Transformation of emotion by emotion; and
  • (6) Corrective experience of emotion through new lived experiences in therapy and in the world.

While primary adaptive emotion responses are seen as a reliable guide for behaviour in the present situation, primary maladaptive emotion responses are seen as an unreliable guide for behaviour in the present situation (alongside other possible emotional difficulties such as lack of emotional awareness, emotion dysregulation, and problems in meaning-making).

Johnson rarely distinguishes between adaptive and maladaptive primary emotion responses, and rarely distinguishes emotion responses as dysfunctional or functional. Instead, primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called “separation distress”. EFT for couples, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element. The patterns of interaction are amenable to change after accessing the underlying primary emotion responses that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotion responses and reprocessing newly accessed primary emotion responses is part of the change process.

Individual Therapy

Goldman & Greenberg 2015 proposed a 14-step case formulation process that regards emotion-related problems as stemming from at least four different possible causes: lack of awareness or avoidance of emotion, dysregulation of emotion, maladaptive emotion response, or a problem with making meaning of experiences. The theory features four types of emotion response (refer to Emotion Response Types below), categorises needs under “attachment” and “identity”, specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers (refer to Therapeutic Tasks below), relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model of psychological development and an emotion schematic system.

The emotion schematic system is seen as the central catalyst of self-organisation, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of co-activated emotion schemes co-apply, to produce a unified sense of self in relation to the world.

Techniques used in “coaching clients to work through their feelings” may include the Gestalt therapy empty chair technique, frequently used for resolving “unfinished business”, and the two-chair technique, frequently used for self-critical splits.

Emotion Response Types

Emotion-focused theorists have posited that each person’s emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time, but for practical purposes emotional responses can be classified into four broad types:

  1. Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value in the present situation—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolised and worked through in therapy. Primary adaptive emotion responses “are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving.”
  2. Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are based on emotion schemes that are no longer useful (and that may or may not have been useful in the person’s past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person’s angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful. Primary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.
  3. Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. (“Secondary” means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defences against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men’s gender role), or expressing sadness when primarily angry (stereotypical of women’s gender role). “These are all complex, self-reflexive processes of reacting to one’s emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse.” Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.
  4. Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, “such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us.” Instrumental emotion responses can be consciously intended or unconsciously learned (i.e. through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.

The Therapeutic Process with Different Emotion Responses

Emotion-focused theorists have proposed that each type of emotion response calls for a different intervention process by the therapist. Primary adaptive emotion responses need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotion responses need to be accessed and explored to help the client identify core unmet needs (e.g. for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotion responses need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotion responses need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client’s situation.

Primary emotion responses are not called “primary” because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client’s situation and how to intervene appropriately.

Therapeutic Tasks

A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients’ cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change. This kind of psychotherapy process research eventually led to a standardised (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.

The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.

In addition to the task markers, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.

Experienced therapists can create new tasks; EFT therapist Robert Elliott, in a 2010 interview, noted that “the highest level of mastery of the therapy—EFT included—is to be able to create new structures, new tasks. You haven’t really mastered EFT or some other therapy until you actually can begin to create new tasks.”

Emotion-Focused Therapy for Trauma

Refer to Complex Post Traumatic Stress Disorder.

The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors. A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published. For example, modifications of the traditional Gestalt empty chair technique have been developed.

Other Versions of EFT for Individuals

Brubacher (2017) proposed an emotionally focused approach to individual therapy that focuses on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation. The therapist follows the attachment model by addressing deactivating and hyperactivating strategies. Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide therapy in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of “effective dependency” (following John Bowlby) upon one or two safe others, depathologising emotion by normalising separation distress responses, and shaping change processes. The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.

Gayner (2019) integrated EFT principles and methods with mindfulness-based cognitive therapy and mindfulness-based stress reduction.

Couples Therapy

A systemic perspective is important in all approaches to EFT for couples. Tracking conflictual patterns of interaction, often referred to as a “dance” in Johnson’s popular literature, has been a hallmark of the first stage of Johnson and Greenberg’s approach since its inception in 1985. In Goldman and Greenberg’s newer approach, therapists help clients “also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change.” Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:

In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person’s core emotion is one of shame and they feel “rotten at the core” or “simply fundamentally flawed,” soothing or reassuring from one’s partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.

In Greenberg and Goldman’s approach to EFT for couples, although they “fully endorse” the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking. In Johnson’s approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.

In Greenberg and Goldman’s approach, the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change. In Johnson’s approach, the primary goal is to reshape attachment bonds and create “effective dependency” (including secure attachment).

Stages and Steps

EFT for couples features a nine-step model of restructuring the attachment bond between partners. In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and “effective dependency”, increasing individuals’ self-regulation and resilience. In good-outcome cases, the couple is helped to respond and thereby meet each other’s unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to a traumatic experience from within and outside of the relationship.

Adding to the original three-stage, nine-step EFT framework developed by Johnson and Greenberg, Greenberg and Goldman’s emotion-focused therapy for couples has five stages and 14 steps. It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.

Johnson (2008) summarizes the nine treatment steps in Johnson’s model of EFT for couples: “The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other.”

Stage 1. Stabilisation (Assessment and De-escalation Phase)

  • Step 1: Identify the relational conflict issues between the partners
  • Step 2: Identify the negative interaction cycle where these issues are expressed
  • Step 3: Access attachment emotions underlying the position each partner takes in this cycle
  • Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs

During this stage, the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple’s positive and negative interactions from past and present and is able to summarise and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

Stage 2. Restructuring the Bond (Changing Interactional Positions Phase)

  • Step 5: Access disowned or implicit needs (e.g. need for reassurance), emotions (e.g. shame), and models of self
  • Step 6: Promote each partner’s acceptance of the other’s experience
  • Step 7: Facilitate each partner’s expression of needs and wants to restructure the interaction based on new understandings and create bonding events

This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognising their attachment needs and then changing their interactions based on those needs. At first, their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behaviour from re-emerging.

Stage 3. Integration and Consolidation

  • Step 8: Facilitate the formulation of new stories and new solutions to old problems
  • Step 9: Consolidate new cycles of behaviour

This stage focuses on the reflection of new emotional experiences and self-concepts. It integrates the couple’s new ways of dealing with problems within themselves and in the relationship.

Styles of Attachment

Johnson & Sims (2000) described four attachment styles that affect the therapy process:

  1. Secure attachment: People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
  2. Avoidant attachment: People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
  3. Anxious attachment: People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner’s attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
  4. Fearful–avoidant attachment: People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility. This is sometimes referred to as disorganised attachment.

Family Therapy

The emotionally focused family therapy (EFFT) of Johnson and her colleagues aims to promote secure bonds among distressed family members. It is a therapy approach consistent with the attachment-oriented experiential–systemic emotionally focused model in three stages:

  • (1) De-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children;
  • (2) restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base; and
  • (3) consolidation of the new responsive cycles and secure bonds.

Its primary focus is on strengthening parental responsiveness and care-giving, to meet children and adolescents’ attachment needs. It aims to “build stronger families through:

  • (1) recruiting and strengthening parental emotional responsiveness to children,
  • (2) accessing and clarifying children’s attachment needs, and
  • (3) facilitating and shaping care-giving interactions from parent to child”.

Some clinicians have integrated EFFT with play therapy.

One group of clinicians, inspired in part by Greenberg’s approach to EFT, developed a treatment protocol specifically for families of individuals struggling with an eating disorder. The treatment is based on the principles and techniques of four different approaches:

  1. Emotion-focused therapy;
  2. Behavioural family therapy;
  3. Motivational enhancement therapy; and
  4. The New Maudsley family skills-based approach.

It aims to help parents “support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences”. The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg’s emotion-focused approach and influenced by John Gottman:

  • (1) Attending to the child’s emotional experience;
  • (2) Naming the emotions;
  • (3) Validating the emotional experience;
  • (4) Meeting the emotional need; and
  • (5) Helping the child to move through the emotional experience, problem solving if necessary.

Efficacy

Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.

The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression. Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.

Practitioners of EFT have claimed that studies have consistently shown clinically significant improvement post therapy. Studies, again mostly by EFT practitioners, have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results. Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy had a larger effect size than any other couple intervention had achieved to date, but this meta-analysis was later harshly criticised by psychologist James C. Coyne, who called it “a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab”. A study with an fMRI component conducted in collaboration with American neuroscientist Jim Coan suggested that emotionally focused couples therapy reduces the brain’s response to threat in the presence of a romantic partner; this study was also criticised by Coyne.

A 2019 meta-analysis on EFT effectiveness for couples therapy concluded that the approach significantly improves relationship satisfaction, with these improvements being sustained for up to two years at follow-up.

Strengths

Some of the strengths of EFT approaches can be summarised as follows:

  • EFT aims to be collaborative and respectful of clients, combining experiential person-centred therapy techniques with systemic therapy interventions.
  • Change strategies and interventions are specified through intensive analysis of psychotherapy process.
  • EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.
  • EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.
  • EFT for couples is based on conceptualisations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.

Criticism

Psychotherapist Campbell Purton, in his 2014 book The Trouble with Psychotherapy, criticised a variety of approaches to psychotherapy, including behaviour therapy, person-centred therapy, psychodynamic therapy, cognitive behavioural therapy, emotion-focused therapy, and existential therapy; he argued that these psychotherapies have accumulated excessive and/or flawed theoretical baggage that deviates too much from an everyday common-sense understanding of personal troubles. With regard to emotion-focused therapy, Purton argued that “the effectiveness of each of the ‘therapeutic tasks’ can be understood without the theory”  and that what clients say “is not well explained in terms of the interaction of emotion schemes; it is better explained in terms of the person’s situation, their response to it, and their having learned the particular language in which they articulate their response.” 

In 2014, psychologist James C. Coyne criticized some EFT research for lack of rigor (for example, being underpowered and having high risk of bias), but he also noted that such problems are common in the field of psychotherapy research.

In a 2015 article in Behavioural and Brain Sciences on “memory reconsolidation, emotional arousal and the process of change in psychotherapy”, Richard D. Lane and colleagues summarised a common claim in the literature on emotion-focused therapy that “emotional arousal is a key ingredient in therapeutic change” and that “emotional arousal is critical to psychotherapeutic success”. In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:

The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). […] The same considerations imply that “changing emotion with emotion” (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one’s learned model. “Changing model with mismatch” is the core phenomenology.

Other responses to Lane et al. (2015) argued that their emotion-focused approach “would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems”, and that their model needed further development to account for the diversity of states called “psychopathology” and the relevant maintaining and worsening processes.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Emotionally_focused_therapy >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Psychoneuroimmunology?

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Introduction

Psychoneuroimmunology (PNI), also referred to as psychoendoneuroimmunology (PENI) or psychoneuroendocrinoimmunology (PNEI), is the study of the interaction between psychological processes and the nervous and immune systems of the human body. It is a subfield of psychosomatic medicine. PNI takes an interdisciplinary approach, incorporating psychology, neuroscience, immunology, physiology, genetics, pharmacology, molecular biology, psychiatry, behavioural medicine, infectious diseases, endocrinology, and rheumatology.

The main interests of PNI are the interactions between the nervous and immune systems and the relationships between mental processes and health. PNI studies, among other things, the physiological functioning of the neuroimmune system in health and disease; disorders of the neuroimmune system (autoimmune diseases; hypersensitivities; immune deficiency); and the physical, chemical and physiological characteristics of the components of the neuroimmune system in vitro, in situ, and in vivo.

Brief History

Interest in the relationship between psychiatric syndromes or symptoms and immune function has been a consistent theme since the beginning of modern medicine.

Claude Bernard, a French physiologist of the Muséum national d’Histoire naturelle (National Museum of Natural History in English), formulated the concept of the milieu interieur in the mid-1800s. In 1865, Bernard described the perturbation of this internal state: “… there are protective functions of organic elements holding living materials in reserve and maintaining without interruption humidity, heat and other conditions indispensable to vital activity. Sickness and death are only a dislocation or perturbation of that mechanism” (Bernard, 1865). Walter Cannon, a professor of physiology at Harvard University coined the commonly used term, homeostasis, in his book The Wisdom of the Body, 1932, from the Greek word homoios, meaning similar, and stasis, meaning position. In his work with animals, Cannon observed that any change of emotional state in the beast, such as anxiety, distress, or rage, was accompanied by total cessation of movements of the stomach (Bodily Changes in Pain, Hunger, Fear and Rage, 1915). These studies looked into the relationship between the effects of emotions and perceptions on the autonomic nervous system, namely the sympathetic and parasympathetic responses that initiated the recognition of the freeze, fight or flight response. His findings were published from time to time in professional journals, then summed up in book form in The Mechanical Factors of Digestion, published in 1911.

Hans Selye, a student of Johns Hopkins University and McGill University, and a researcher at Université de Montréal, experimented with animals by putting them under different physical and mental adverse conditions and noted that under these difficult conditions the body consistently adapted to heal and recover. Several years of experimentation that formed the empiric foundation of Selye’s concept of the General Adaptation Syndrome. This syndrome consists of an enlargement of the adrenal gland, atrophy of the thymus, spleen, and other lymphoid tissue, and gastric ulcerations.

Selye describes three stages of adaptation, including an initial brief alarm reaction, followed by a prolonged period of resistance, and a terminal stage of exhaustion and death. This foundational work led to a rich line of research on the biological functioning of glucocorticoids.

Mid-20th century studies of psychiatric patients reported immune alterations in psychotic individuals, including lower numbers of lymphocytes and poorer antibody response to pertussis vaccination, compared with nonpsychiatric control subjects. In 1964, George F. Solomon, from the University of California in Los Angeles, and his research team coined the term “psychoimmunology” and published a landmark paper: “Emotions, immunity, and disease: a speculative theoretical integration.”

Origins

In 1975, Robert Ader and Nicholas Cohen, at the University of Rochester, advanced PNI with their demonstration of classic conditioning of immune function, and they subsequently coined the term “psychoneuroimmunology”. Ader was investigating how long conditioned responses (in the sense of Pavlov’s conditioning of dogs to drool when they heard a bell ring) might last in laboratory rats. To condition the rats, he used a combination of saccharin-laced water (the conditioned stimulus) and the drug Cytoxan, which unconditionally induces nausea and taste aversion and suppression of immune function. Ader was surprised to discover that after conditioning, just feeding the rats saccharin-laced water was associated with the death of some animals and he proposed that they had been immunosuppressed after receiving the conditioned stimulus. Ader (a psychologist) and Cohen (an immunologist) directly tested this hypothesis by deliberately immunising conditioned and unconditioned animals, exposing these and other control groups to the conditioned taste stimulus, and then measuring the amount of antibody produced. The highly reproducible results revealed that conditioned rats exposed to the conditioned stimulus were indeed immunosuppressed. In other words, a signal via the nervous system (taste) was affecting immune function. This was one of the first scientific experiments that demonstrated that the nervous system can affect the immune system.

In the 1970s, Hugo Besedovsky, Adriana del Rey and Ernst Sorkin, working in Switzerland, reported multi-directional immune-neuro-endocrine interactions, since they show that not only the brain can influence immune processes but also the immune response itself can affect the brain and neuroendocrine mechanisms. They found that the immune responses to innocuous antigens triggers an increase in the activity of hypothalamic neurons and hormonal and autonomic nerve responses that are relevant for immunoregulation and are integrated at brain levels. On these bases, they proposed that the immune system acts as a sensorial receptor organ that, besides its peripheral effects, can communicate to the brain and associated neuro-endocrine structures its state of activity. These investigators also identified products from immune cells, later characterised as cytokines, that mediate this immune-brain communication.

In 1981, David L. Felten, then working at the Indiana University School of Medicine, and his colleague JM Williams, discovered a network of nerves leading to blood vessels as well as cells of the immune system. The researchers also found nerves in the thymus and spleen terminating near clusters of lymphocytes, macrophages, and mast cells, all of which help control immune function. This discovery provided one of the first indications of how neuro-immune interaction occurs.

Ader, Cohen, and Felten went on to edit the groundbreaking book Psychoneuroimmunology in 1981, which laid out the underlying premise that the brain and immune system represent a single, integrated system of defence.

In 1985, research by neuropharmacologist Candace Pert, of the National Institutes of Health at Georgetown University, revealed that neuropeptide-specific receptors are present on the cell walls of both the brain and the immune system. The discovery that neuropeptides and neurotransmitters act directly upon the immune system shows their close association with emotions and suggests mechanisms through which emotions, from the limbic system, and immunology are deeply interdependent. Showing that the immune and endocrine systems are modulated not only by the brain but also by the central nervous system itself affected the understanding of emotions, as well as disease.

Contemporary advances in psychiatry, immunology, neurology, and other integrated disciplines of medicine has fostered enormous growth for PNI. The mechanisms underlying behaviourally induced alterations of immune function, and immune alterations inducing behavioural changes, are likely to have clinical and therapeutic implications that will not be fully appreciated until more is known about the extent of these interrelationships in normal and pathophysiological states.

The Immune-Brain Loop

PNI research looks for the exact mechanisms by which specific neuroimmune effects are achieved. Evidence for nervous-immunological interactions exist at multiple biological levels.

The immune system and the brain communicate through signalling pathways. The brain and the immune system are the two major adaptive systems of the body. Two major pathways are involved in this cross-talk: the Hypothalamic-pituitary-adrenal axis (HPA axis), and the sympathetic nervous system (SNS), via the sympathetic-adrenal-medullary axis (SAM axis). The activation of SNS during an immune response might be aimed to localise the inflammatory response.

The body’s primary stress management system is the HPA axis. The HPA axis responds to physical and mental challenge to maintain homeostasis in part by controlling the body’s cortisol level. Dysregulation of the HPA axis is implicated in numerous stress-related diseases, with evidence from meta-analyses indicating that different types/duration of stressors and unique personal variables can shape the HPA response. HPA axis activity and cytokines are intrinsically intertwined: inflammatory cytokines stimulate adrenocorticotropic hormone (ACTH) and cortisol secretion, while, in turn, glucocorticoids suppress the synthesis of proinflammatory cytokines.

Molecules called pro-inflammatory cytokines, which include interleukin-1 (IL-1), Interleukin-2 (IL-2), interleukin-6 (IL-6), Interleukin-12 (IL-12), Interferon-gamma (IFN-Gamma) and tumour necrosis factor alpha (TNF-alpha) can affect brain growth as well as neuronal function. Circulating immune cells such as macrophages, as well as glial cells (microglia and astrocytes) secrete these molecules. Cytokine regulation of hypothalamic function is an active area of research for the treatment of anxiety-related disorders.

Cytokines mediate and control immune and inflammatory responses. Complex interactions exist between cytokines, inflammation and the adaptive responses in maintaining homeostasis. Like the stress response, the inflammatory reaction is crucial for survival. Systemic inflammatory reaction results in stimulation of four major programmes:

  • The acute-phase reaction;
  • Sickness behaviour;
  • The pain programme; and
  • The stress response.

These are mediated by the HPA axis and the SNS. Common human diseases such as allergy, autoimmunity, chronic infections and sepsis are characterised by a dysregulation of the pro-inflammatory versus anti-inflammatory and T helper (Th1) versus (Th2) cytokine balance. Recent studies show pro-inflammatory cytokine processes take place during depression, mania and bipolar disease, in addition to autoimmune hypersensitivity and chronic infections.

Chronic secretion of stress hormones, glucocorticoids (GCs) and catecholamines (CAs), as a result of disease, may reduce the effect of neurotransmitters, including serotonin, norepinephrine and dopamine, or other receptors in the brain, thereby leading to the dysregulation of neurohormones. Under stimulation, norepinephrine is released from the sympathetic nerve terminals in organs, and the target immune cells express adrenoreceptors. Through stimulation of these receptors, locally released norepinephrine, or circulating catecholamines such as epinephrine, affect lymphocyte traffic, circulation, and proliferation, and modulate cytokine production and the functional activity of different lymphoid cells.

Glucocorticoids also inhibit the further secretion of corticotropin-releasing hormone from the hypothalamus and ACTH from the pituitary (negative feedback). Under certain conditions stress hormones may facilitate inflammation through induction of signalling pathways and through activation of the corticotropin-releasing hormone.

These abnormalities and the failure of the adaptive systems to resolve inflammation affect the well-being of the individual, including behavioural parameters, quality of life and sleep, as well as indices of metabolic and cardiovascular health, developing into a “systemic anti-inflammatory feedback” and/or “hyperactivity” of the local pro-inflammatory factors which may contribute to the pathogenesis of disease.

This systemic or neuro-inflammation and neuroimmune activation have been shown to play a role in the aetiology of a variety of neurodegenerative disorders such as Parkinson’s and Alzheimer’s disease, multiple sclerosis, pain, and AIDS-associated dementia. However, cytokines and chemokines also modulate central nervous system (CNS) function in the absence of overt immunological, physiological, or psychological challenges.

Psychoneuroimmunological Effects

There are now sufficient data to conclude that immune modulation by psychosocial stressors and/or interventions can lead to actual health changes. Although changes related to infectious disease and wound healing have provided the strongest evidence to date, the clinical importance of immunological dysregulation is highlighted by increased risks across diverse conditions and diseases. For example, stressors can produce profound health consequences. In one epidemiological study, all-cause mortality increased in the month following a severe stressor – the death of a spouse. Theorists propose that stressful events trigger cognitive and affective responses which, in turn, induce sympathetic nervous system and endocrine changes, and these ultimately impair immune function. Potential health consequences are broad, but include rates of infection HIV progression cancer incidence and progression, and high rates of infant mortality.

Understanding Stress and Immune Function

Stress is thought to affect immune function through emotional and/or behavioural manifestations such as anxiety, fear, tension, anger and sadness and physiological changes such as heart rate, blood pressure, and sweating. Researchers have suggested that these changes are beneficial if they are of limited duration, but when stress is chronic, the system is unable to maintain equilibrium or homeostasis; the body remains in a state of arousal, where digestion is slower to reactivate or does not reactivate properly, often resulting in indigestion. Furthermore, blood pressure stays at higher levels.

In one of the earlier PNI studies, which was published in 1960, subjects were led to believe that they had accidentally caused serious injury to a companion through misuse of explosives. Since then decades of research resulted in two large meta-analyses, which showed consistent immune dysregulation in healthy people who are experiencing stress.

In the first meta-analysis by Herbert and Cohen in 1993, they examined 38 studies of stressful events and immune function in healthy adults. They included studies of acute laboratory stressors (e.g. a speech task), short-term naturalistic stressors (e.g. medical examinations), and long-term naturalistic stressors (e.g. divorce, bereavement, caregiving, unemployment). They found consistent stress-related increases in numbers of total white blood cells, as well as decreases in the numbers of helper T cells, suppressor T cells, and cytotoxic T cells, B cells, and natural killer cells (NK). They also reported stress-related decreases in NK and T cell function, and T cell proliferative responses to phytohaemagglutinin [PHA] and concanavalin A [Con A]. These effects were consistent for short-term and long-term naturalistic stressors, but not laboratory stressors.

In the second meta-analysis by Zorrilla et al. in 2001, they replicated Herbert and Cohen’s meta-analysis. Using the same study selection procedures, they analysed 75 studies of stressors and human immunity. Naturalistic stressors were associated with increases in number of circulating neutrophils, decreases in number and percentages of total T cells and helper T cells, and decreases in percentages of natural killer cell (NK) cells and cytotoxic T cell lymphocytes. They also replicated Herbert and Cohen’s finding of stress-related decreases in NKCC and T cell mitogen proliferation to phytohaemagglutinin (PHA) and concanavalin A (Con A).

A study done by the American Psychological Association did an experiment on rats, where they applied electrical shocks to a rat, and saw how interleukin-1 was released directly into the brain. Interleukin-1 is the same cytokine released when a macrophage chews on a bacterium, which then travels up the vagus nerve, creating a state of heightened immune activity, and behavioural changes.

More recently, there has been increasing interest in the links between interpersonal stressors and immune function. For example, marital conflict, loneliness, caring for a person with a chronic medical condition, and other forms on interpersonal stress dysregulate immune function.

Communication between the Brain and Immune System

  • Stimulation of brain sites alters immunity (stressed animals have altered immune systems).
  • Damage to brain hemispheres alters immunity (hemispheric lateralisation effects).
  • Immune cells produce cytokines that act on the CNS.
  • Immune cells respond to signals from the CNS.

Communication between Neuroendocrine and Immune System

  • Glucocorticoids and catecholamines influence immune cells.
  • Hypothalamic Pituitary Adrenal axis releases the needed hormones to support the immune system.
  • Activity of the immune system is correlated with neurochemical/neuroendocrine activity of brain cells.

Connections between Glucocorticoids and Immune System

  • Anti-inflammatory hormones that enhance the organism’s response to a stressor.
  • Prevent the overreaction of the body’s own defence system.
  • Overactivation of glucocorticoid receptors can lead to health risks.
  • Regulators of the immune system.
  • Affect cell growth, proliferation and differentiation.
  • Cause immunosuppression which can lead to an extended amount of time fighting off infections.
  • High basal levels of cortisol are associated with a higher risk of infection.
  • Suppress cell adhesion, antigen presentation, chemotaxis and cytotoxicity.
  • Increase apoptosis.

Corticotropin-Releasing Hormone (CRH)

Release of corticotropin-releasing hormone (CRH) from the hypothalamus is influenced by stress.

  • CRH is a major regulator of the HPA axis/stress axis.
  • CRH Regulates secretion of adrenocorticotropic hormone (ACTH).
  • CRH is widely distributed in the brain and periphery
  • CRH also regulates the actions of the Autonomic nervous system ANS and immune system.

Furthermore, stressors that enhance the release of CRH suppress the function of the immune system; conversely, stressors that depress CRH release potentiate immunity.

  • Central mediated since peripheral administration of CRH antagonist does not affect immunosuppression.
  • HPA axis/stress axis responds consistently to stressors that are new, unpredictable and that have low-perceived control.
  • As cortisol reaches an appropriate level in response to the stressor, it deregulates the activity of the hippocampus, hypothalamus, and pituitary gland which results in less production of cortisol.

Relationships between Prefrontal Cortex Activation and Cellular Senescence

  • Psychological stress is regulated by the prefrontal cortex (PFC).
  • The PFC modulates vagal activity.
  • Prefrontally modulated and vagally mediated cholinergic input to the spleen reduces inflammatory responses.

Pharmaceutical Advances

Glutamate agonists, cytokine inhibitors, vanilloid-receptor agonists, catecholamine modulators, ion-channel blockers, anticonvulsants, GABA agonists (including opioids and cannabinoids), COX inhibitors, acetylcholine modulators, melatonin analogues (such as Ramelton), adenosine receptor antagonists and several miscellaneous drugs (including biologics like Passiflora edulis) are being studied for their psychoneuroimmunological effects.

For example, SSRIs, SNRIs and tricyclic antidepressants acting on serotonin, norepinephrine, dopamine and cannabinoid receptors have been shown to be immunomodulatory and anti-inflammatory against pro-inflammatory cytokine processes, specifically on the regulation of IFN-gamma and IL-10, as well as TNF-alpha and IL-6 through a psychoneuroimmunological process. Antidepressants have also been shown to suppress TH1 upregulation.

Tricyclic and dual serotonergic-noradrenergic reuptake inhibition by SNRIs (or SSRI-NRI combinations), have also shown analgesic properties additionally. According to recent evidences antidepressants also seem to exert beneficial effects in experimental autoimmune neuritis in rats by decreasing Interferon-beta (IFN-beta) release or augmenting NK activity in depressed patients.

These studies warrant investigation of antidepressants for use in both psychiatric and non-psychiatric illness and that a psychoneuroimmunological approach may be required for optimal pharmacotherapy in many diseases. Future antidepressants may be made to specifically target the immune system by either blocking the actions of pro-inflammatory cytokines or increasing the production of anti-inflammatory cytokines.

The endocannabinoid system appears to play a significant role in the mechanism of action of clinically effective and potential antidepressants and may serve as a target for drug design and discovery. The endocannabinoid-induced modulation of stress-related behaviours appears to be mediated, at least in part, through the regulation of the serotoninergic system, by which cannabinoid CB1 receptors modulate the excitability of dorsal raphe serotonin neurons. Data suggest that the endocannabinoid system in cortical and subcortical structures is differentially altered in an animal model of depression and that the effects of chronic, unpredictable stress (CUS) on CB1 receptor binding site density are attenuated by antidepressant treatment while those on endocannabinoid content are not.

The increase in amygdalar CB1 receptor binding following imipramine treatment is consistent with prior studies which collectively demonstrate that several treatments which are beneficial to depression, such as electroconvulsive shock and tricyclic antidepressant treatment, increase CB1 receptor activity in subcortical limbic structures, such as the hippocampus, amygdala and hypothalamus. And preclinical studies have demonstrated the CB1 receptor is required for the behavioural effects of noradrenergic based antidepressants but is dispensable for the behavioural effect of serotonergic based antidepressants.

Extrapolating from the observations that positive emotional experiences boost the immune system, Roberts speculates that intensely positive emotional experiences—sometimes brought about during mystical experiences occasioned by psychedelic medicines—may boost the immune system powerfully. Research on salivary IgA supports this hypothesis, but experimental testing has not been done.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Psychoneuroimmunology >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is a Neurohospitalist?

Published on by Andrew Marshall1 Comment

Introduction

Neurohospitalist is a term used for physicians interested in inpatient neurological care.

It is an emerging subspecialty of neurology and a growing branch of neurology-internal medicine cross-functional care.

Journal

The Neurohospitalist is a quarterly, international, peer-reviewed journal dedicated to the practice and performance of neurohospitalist medicine.

The Neurohospitalist Society

The Neurohospitalist Society (NHS) was formed to create a central unifying organisation of neurohospitalists. Neurohospitalists are physicians and providers who care for hospitalised patients with, or at risk for, neurological disorders and disease.

History of the Neurohospitalist

In the early 2000s, “the term hospitalist was coined to describe specialists in internal medicine, whose focus was primarily on inpatient care.”

You can read about the “The Birth of Neurohospitalists” by William D. Freeman and S. Andrew Josephson here.

In the inaugural issue of The Neurohospitalist (January 2011), the authors sought to address 4 fundamental questions about neurohospitalists:

  1. What is a neurohospitalist?
  2. What fuelled the “birth” and growth of neurohospitalists?
  3. What are the different functions of a neurohospitalist compared to other neurologists?; and
  4. What areas of research will define this subspecialty (e.g. other than stroke and neurocritical care)?

What Illnesses do Neurohospitalists Treat?

Neurohospitalists see and treat a wide variety of illnesses ranging from autoimmune encephalitis to acute myasthenia gravis exacerbation, Guillain-Barre syndrome, refractory epilepsy, meningitis, headache, primary and secondary brain cancers, and delirium.

Neurology vs Neurohospitalist

In contrast to traditional neurology subspecialty practice that is outpatient-centred and disease specific, neurology hospitalists or “neurohospitalists” specialise in the care of patients admitted to the hospital with a wide array of nervous system disorders.

A neurohospitalist is (generally) a neurologist who has completed additional training to care for acutely ill, clinically complex patients with neurologic disease.

An Overview of Neurology

Published on by Andrew Marshall2 Comments

Introduction

Neurology (from Greek: νεῦρον (neûron), “string, nerve” and the suffix -logia, “study of”) is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the nervous system, which comprises the brain, the spinal cord and the peripheral nerves. Neurological practice relies heavily on the field of neuroscience, the scientific study of the nervous system.

A neurologist is a physician specialising in neurology and trained to investigate, diagnose and treat neurological disorders. Neurologists diagnose and treat myriad neurologic conditions, including stroke, epilepsy, movement disorders such as Parkinson’s disease, brain infections, autoimmune neurologic disorders such as multiple sclerosis, sleep disorders, brain injury, headache disorders like migraine, tumours of the brain and dementias such as Alzheimer’s disease. Neurologists may also have roles in clinical research, clinical trials, and basic or translational research. Neurology is a nonsurgical specialty, its corresponding surgical specialty is neurosurgery.

Refer to neurohospitalist.

Brief History

The academic discipline began between the 15th and 16th centuries with the work and research of many neurologists such as Thomas Willis, Robert Whytt, Matthew Baillie, Charles Bell, Moritz Heinrich Romberg, Duchenne de Boulogne, William A. Hammond, Jean-Martin Charcot, C. Miller Fisher and John Hughlings Jackson. Neo-Latin neurologia appeared in various texts from 1610 denoting an anatomical focus on the nerves (variably understood as vessels), and was most notably used by Willis, who preferred Greek νευρολογία.

Training

In the United States and Canada, neurologists are physicians who have completed a postgraduate training period known as residency specialising in neurology after graduation from medical school. This additional training period typically lasts four years, with the first year devoted to training in internal medicine. On average, neurologists complete a total of eight to ten years of training. This includes four years of medical school, four years of residency and an optional one to two years of fellowship.

While neurologists may treat general neurologic conditions, some neurologists go on to receive additional training focusing on a particular subspecialty in the field of neurology. These training programs are called fellowships, and are one to two years in duration. Subspecialties in the United States include brain injury medicine, clinical neurophysiology, epilepsy, neurodevelopmental disabilities, neuromuscular medicine, pain medicine, sleep medicine, neurocritical care, vascular neurology (stroke), behavioural neurology, child neurology, headache, neuroimmunology and infectious disease, movement disorders, neuroimaging, neurooncology, and neurorehabilitation.

In Germany, a compulsory year of psychiatry must be done to complete a residency of neurology.

In the United Kingdom and Ireland, neurology is a subspecialty of general (internal) medicine. After five years of medical school and two years as a Foundation Trainee, an aspiring neurologist must pass the examination for Membership of the Royal College of Physicians (or the Irish equivalent) and complete two years of core medical training before entering specialist training in neurology. Up to the 1960s, some intending to become neurologists would also spend two years working in psychiatric units before obtaining a diploma in psychological medicine. However, that was uncommon and, now that the MRCPsych takes three years to obtain, would no longer be practical. A period of research is essential, and obtaining a higher degree aids career progression. Many found it was eased after an attachment to the Institute of Neurology at Queen Square, London. Some neurologists enter the field of rehabilitation medicine (known as physiatry in the US) to specialise in neurological rehabilitation, which may include stroke medicine, as well as traumatic brain injuries.

Physical Examination

During a neurological examination, the neurologist reviews the patient’s health history with special attention to the patient’s neurologic complaints. The patient then takes a neurological exam. Typically, the exam tests mental status, function of the cranial nerves (including vision), strength, coordination, reflexes, sensation and gait. This information helps the neurologist determine whether the problem exists in the nervous system and the clinical localization. Localisation of the pathology is the key process by which neurologists develop their differential diagnosis. Further tests may be needed to confirm a diagnosis and ultimately guide therapy and appropriate management. Useful adjunct imaging studies in neurology include CT scanning and MRI. Other tests used to assess muscle and nerve function include nerve conduction studies and electromyography.

Clinical Tasks

Neurologists examine patients who are referred to them by other physicians in both the inpatient and outpatient settings. Neurologists begin their interactions with patients by taking a comprehensive medical history, and then performing a physical examination focusing on evaluating the nervous system. Components of the neurological examination include assessment of the patient’s cognitive function, cranial nerves, motor strength, sensation, reflexes, coordination, and gait.

In some instances, neurologists may order additional diagnostic tests as part of the evaluation. Commonly employed tests in neurology include imaging studies such as computed axial tomography (CAT) scans, magnetic resonance imaging (MRI), and ultrasound of major blood vessels of the head and neck. Neurophysiologic studies, including electroencephalography (EEG), needle electromyography (EMG), nerve conduction studies (NCSs) and evoked potentials are also commonly ordered. Neurologists frequently perform lumbar punctures to assess characteristics of a patient’s cerebrospinal fluid. Advances in genetic testing have made genetic testing an important tool in the classification of inherited neuromuscular disease and diagnosis of many other neurogenetic diseases. The role of genetic influences on the development of acquired neurologic diseases is an active area of research.

Some of the commonly encountered conditions treated by neurologists include headaches, radiculopathy, neuropathy, stroke, dementia, seizures and epilepsy, Alzheimer’s disease, attention deficit/hyperactivity disorder, Parkinson’s disease, Tourette’s syndrome, multiple sclerosis, head trauma, sleep disorders, neuromuscular diseases, and various infections and tumours of the nervous system. Neurologists are also asked to evaluate unresponsive patients on life support to confirm brain death.

Treatment options vary depending on the neurological problem. They can include referring the patient to a physiotherapist, prescribing medications, or recommending a surgical procedure.

Some neurologists specialise in certain parts of the nervous system or in specific procedures. For example, clinical neurophysiologists specialise in the use of EEG and intraoperative monitoring to diagnose certain neurological disorders. Other neurologists specialise in the use of electrodiagnostic medicine studies – needle EMG and NCSs. In the US, physicians do not typically specialize in all the aspects of clinical neurophysiology – i.e. sleep, EEG, EMG, and NCSs. The American Board of Clinical Neurophysiology certifies US physicians in general clinical neurophysiology, epilepsy, and intraoperative monitoring. The American Board of Electrodiagnostic Medicine certifies US physicians in electrodiagnostic medicine and certifies technologists in nerve-conduction studies. Sleep medicine is a subspecialty field in the US under several medical specialties including anaesthesiology, internal medicine, family medicine, and neurology. Neurosurgery is a distinct specialty that involves a different training path and emphasizes the surgical treatment of neurological disorders.

Also, many nonmedical doctors, those with doctoral degrees (usually PhDs) in subjects such as biology and chemistry, study and research the nervous system. Working in laboratories in universities, hospitals, and private companies, these neuroscientists perform clinical and laboratory experiments and tests to learn more about the nervous system and find cures or new treatments for diseases and disorders.

A great deal of overlap occurs between neuroscience and neurology. Many neurologists work in academic training hospitals, where they conduct research as neuroscientists in addition to treating patients and teaching neurology to medical students.

General Caseload

Neurologists are responsible for the diagnosis, treatment, and management of all the conditions mentioned above. When surgical or endovascular intervention is required, the neurologist may refer the patient to a neurosurgeon or an interventional neuroradiologist. In some countries, additional legal responsibilities of a neurologist may include making a finding of brain death when it is suspected that a patient has died. Neurologists frequently care for people with hereditary (genetic) diseases when the major manifestations are neurological, as is frequently the case. Lumbar punctures are frequently performed by neurologists. Some neurologists may develop an interest in particular subfields, such as stroke, dementia, movement disorders, neurointensive care, headaches, epilepsy, sleep disorders, chronic pain management, multiple sclerosis, or neuromuscular diseases.

Overlapping Areas

Some overlap also occurs with other specialties, varying from country to country and even within a local geographic area. Acute head trauma is most often treated by neurosurgeons, whereas sequelae of head trauma may be treated by neurologists or specialists in rehabilitation medicine. Although stroke cases have been traditionally managed by internal medicine or hospitalists, the emergence of vascular neurology and interventional neuroradiology has created a demand for stroke specialists. The establishment of Joint Commission-certified stroke centres has increased the role of neurologists in stroke care in many primary, as well as tertiary, hospitals. Some cases of nervous system infectious diseases are treated by infectious disease specialists. Most cases of headache are diagnosed and treated primarily by general practitioners, at least the less severe cases. Likewise, most cases of sciatica are treated by general practitioners, though they may be referred to neurologists or surgeons (neurosurgeons or orthopaedic surgeons). Sleep disorders are also treated by pulmonologists and psychiatrists. Cerebral palsy is initially treated by paediatricians, but care may be transferred to an adult neurologist after the patient reaches a certain age. Physical medicine and rehabilitation physicians may treat patients with neuromuscular diseases with electrodiagnostic studies (needle EMG and nerve-conduction studies) and other diagnostic tools. In the United Kingdom and other countries, many of the conditions encountered by older patients such as movement disorders, including Parkinson’s disease, stroke, dementia, or gait disorders, are managed predominantly by specialists in geriatric medicine.

Clinical neuropsychologists are often called upon to evaluate brain-behaviour relationships for the purpose of assisting with differential diagnosis, planning rehabilitation strategies, documenting cognitive strengths and weaknesses, and measuring change over time (e.g. for identifying abnormal ageing or tracking the progression of a dementia).

Relationship to Clinical Neurophysiology

In some countries such as the United States and Germany, neurologists may subspecialise in clinical neurophysiology, the field responsible for EEG and intraoperative monitoring, or in electrodiagnostic medicine nerve conduction studies, EMG, and evoked potentials. In other countries, this is an autonomous specialty (e.g. UK, Sweden, Spain).

Overlap with Psychiatry

Refer to neuropsychiatry.

In the past, prior to the advent of more advanced diagnostic techniques such as MRI some neurologists have considered psychiatry and neurology to overlap. Although mental illnesses are believed by many to be neurological disorders affecting the central nervous system, traditionally they are classified separately, and treated by psychiatrists. In a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote:

“the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway”.

Neurological disorders often have psychiatric manifestations, such as post-stroke depression, depression and dementia associated with Parkinson’s disease, mood and cognitive dysfunctions in Alzheimer’s disease, and Huntington disease, to name a few. Hence, the sharp distinction between neurology and psychiatry is not always on a biological basis. The dominance of psychoanalytic theory in the first three-quarters of the 20th century has since then been largely replaced by a focus on pharmacology. Despite the shift to a medical model, brain science has not advanced to a point where scientists or clinicians can point to readily discernible pathological lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder.

Neurological Enhancement

The emerging field of neurological enhancement highlights the potential of therapies to improve such things as workplace efficacy, attention in school, and overall happiness in personal lives. However, this field has also given rise to questions about neuroethics.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Neurology >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

An Overview of Services for Mental Disorders

Published on by Andrew MarshallLeave a comment

Introduction

Services for mental health disorders provide treatment, support, or advocacy to people who have psychiatric illnesses. These may include medical, behavioural, social, and legal services.

Medical services are usually provided by mental health experts like psychiatrists, psychologists, and behavioural health counsellors in a hospital or outpatient clinic. Behavioural services go hand-in-hand with medical services, referring specifically to pharmacological and cognitive therapy. Social services are usually provided by the government or non-profit organisations. They arrange housing options, job training, or other community resources overseen by experienced professionals to ensure overall productivity and well-being of individuals with mental illnesses. Legal services ensure that people with mental health disorders are not discriminated against in society and advocate for their basic human rights. In addition, legal services make sure that those individuals who might be a danger to themselves or others are diverted away from the judicial system to receive adequate treatment for underlying mental health issues.

The information provided below is primarily regarding services offered within the US, unless otherwise specified.

Medical Services

There are several types of medical service settings that can serve to deliver mental health care or services. These include, but are not limited to family practice, psychiatric hospitals or clinics, general hospitals, and community mental or behavioural health centres. One medical service that is not used as much is the self-help plan. The self-help plan is where a person with mental illness addresses their condition then find strategies to get better. This may include addressing any triggers, recovery options or warning signs. Different services endorse different payment models. Some may be more government-based or patient-based, while others may endorse mixed-models payment systems. Not all service types or institutions are accessible by all patients. A considerable barrier surrounds the difficulty in finding in-network mental health care providers, given the backdrop of our current and critical nationwide shortage of mental health professionals.

Family practice or general practice centres in communities are often the first line for assessment of mental health conditions. The basic services provided may include prescribing psychiatric drugs and sometimes providing basic counselling or therapy for “common mental disorders.” Secondary medical services may include psychiatric hospitals, or clinics. However, given the trend towards the deinstitutionalisation of mental health hospitals – the movement of mental health patients out of the “asylum-based” mental health care system towards community-oriented care – psychiatric hospitals have been going out of favour, with services being directed to wards within general hospitals as well as more locally based community mental health services.

Mental health services may be provided either on an inpatient or, more commonly, an outpatient basis. A wide range of treatments may be provided to patients, with a mainstay of treatment being centred on psychiatric drugs. However, medication does not cure any mental illness but it does help manage symptoms. Various mental health professionals may be involved including psychiatrists, psychiatric and mental health nurses and, less commonly, non-medical professionals such as clinical psychologists, social workers, and various kinds of therapists or counsellors. Usually headed by psychiatrists and therefore based on a medical model, multidisciplinary teams may be involved in assertive community treatment and early intervention and may be coordinated via a case management system (sometimes referred to as “service coordination”).

Behavioural Therapy Services

Numerous services exist exclusively for the therapy of mental disorders and distress. Since symptoms vary across individuals, therapy is usually individualised for patients. All behaviours can be learned and also can be changed. Behavioural therapy is a method of therapy that is used to help identify unhealthy behaviours and to help change such behaviours. Methods exist that target numerous areas at once, such as integrative psychotherapy (an eclectic tailored mix of approaches). Integrative psychotherapists consider many factors when treating a patient, such as preferences, physical capabilities, or family support. In contrast to integrative psychotherapy, many approaches focus on particular areas. Cognitive behavioural therapy, psychodynamic therapy, interpersonal therapy, and dialectical behavioural therapy are all examples of approaches that have primary focuses when attempting to treat a patient. Conditions that can be treated by these therapies include anxiety, eating disorders, substance use disorders, obsessive compulsive disorders, and insomnia. The chosen therapy depends on several factors, with patient preference being a significant one.

Each type of therapy has its own strengths and weaknesses. Cognitive behavioural therapy is an attempt to allow patients to realise any inaccurate thoughts they may have and to allow them to perceive situations differently. Roughly about 75% of people who have used the cognitive behaviour therapy have experience a great outcome, which shows how effective this type of therapy is. There is also another type of cognitive therapy which is called cognitive behavioural play therapy. This therapy is particularly used for children. It is done by the therapist watching the child play then determining what the child is uncomfortable expressing. Psychodynamic therapy differs from cognitive behavioural therapy in that it is a longer-term therapy that usually requires more sessions for its effectiveness. Psychodynamic therapy is less structured and relies heavily on the relationship between the therapist and the patient. Although cognitive behavioural therapy has become the more favoured form of therapy, psychodynamic therapy continues to be viewed as the more effective treatment. When medication and psychodynamic are being used together it gives a higher chance of recovery. An integrative approach would allow one therapist to implement both cognitive behavioural therapy and psychodynamic therapy while treating the same patient. Interpersonal therapy is highly structured and is usually targeted at depression. There is evidence that suggests interpersonal therapy provides a benefit that is equal to pharmacologic therapy for depression. Dialectical behavioural therapy is an evidence-based psychotherapy that is usually used to treat suicidal behaviours. Each form of behavioural therapy uses different strategies to reach the goal of improving the quality of life for patients.

Social Services

Community-based social services often include supportive housing, clubhouses, and national hotlines. These resources may be provided by people who are successfully living with psychiatric disorders. Peer-led support encourage those individuals struggling with mental health disorders to seek self-help strategies and belong to social support network.

Supportive Housing

Supportive housing is an innovative solution that aims to provide permanent, accessible, and affordable housing options for individuals with mental health disorders. Additional help is often available to manage one’s finances, daily activities, and healthcare needs. Rent is usually less than 30% of one’s income and is further made affordable through rental assistance programmes offered by the government. It, also, provides access to public transportation as well as healthcare providers and other community resources. In supervised or partially-supervised supportive housing, trained staff may be present to help with medication management, paying bills, cleaning, cooking, and other day-to-day tasks. These environments are usually group home settings, where individuals have their own bedroom and bathroom but share common areas with other residents. Alternatively, individuals may also choose to live in independent supportive housing if they do not require frequent supervision regarding their activities of daily living. It is important to note that tenants have the freedom to choose which services they would like to utilise based on their degree of independence and unmet needs.

One of the limitations that prevent the widespread availability of supportive housing is the cost associated with hiring trained staff and maintaining the building as well as surrounding premises, while still keeping the rent affordable. However, studies have shown that the integrated services offered by supportive housing helps to decrease homelessness, incarceration rates, emergency room visits, and the number of days patients stay in a hospital. Such widespread effects can promote the lowering of costs associated with services in the above-mentioned areas and these funds can be diverted to sustain supportive housing projects.

Clubhouse Model

Clubhouses are community centres that are usually run by individuals who have a current or previous history of mental illness. The main purpose of these establishments is to promote rehabilitation and self-sufficiency of individuals by offering them employment opportunities. This includes access to community workshops, job training programmes, and educational opportunities. Additionally, clubhouse staff may maintain partnerships with local employers to provide full-time or part-time employment opportunities. Members, also, have access to social events and team-based activities, which helps them to develop a social support network.

Phone-Based Services

A mental health hotline is a free, confidential, and convenient way to receive information regarding various mental health services that are available in the community. The hotline is operated by trained employees and volunteers who can connect callers with the appropriate medical, legal, or social resources. There are no restrictions regarding how many times an individual may utilise a particular hotline. Some services may be available 24 hours a day, 7 days a week and via text messaging applications.

A few phone-based services exclusively deal with mental health emergencies or crisis situations, such as suicide and substance abuse. Suicide prevention lifelines are operated by mental health counsellors or community volunteers. They are trained to identify suicide risk, de-escalate an emergent crisis, and provide emotional support for those in distress. Substance abuse and relapse helplines provide behavioural support to those struggling with addiction as well as connect them with rehabilitation centres for treatment.

Phone-based services also allow for providers to remove language barriers. This is due to the fact that there are several online translation services in order to record and relay information in real time, across several different languages. By eliminating language barriers, providers are also able to prevent patients from experiencing social prejudice. Patients can now reach out to a wider variety of providers and are no longer bound to their local community practitioners, where there could be added stigma.

Telehealth Services

The use of Telehealth, health related services distributed electronically, has exploded in popularity across the world of medicine following the 2019-2020 COVID-19 pandemic. Remote health services have opened up a new dimension for healthcare providers to provide care to patients with efficiency and a wider range of accessibility. The inclusion of mental health services in this expansion has helped dispel the belief that mental health is not capable of being done electronically and has opened up new possibilities in the field of mental health services, and service provision. There are still limits restricting Telehealth including the fact that many people still do not have access to technology such as phones and computers, and that it cannot replace more intensive treatment settings.

Apps Providing Psychological Services

Mental health apps are an increasingly popular means of providing mental health services. They are cost effective, easy to access at almost any location, affordable, anonymous, can provide around the clock support, can reach a greater number of people, and are capable of providing a supporting role to other services for mental disorders. Even though apps have great potential to accomplish new and innovative goals in the field of mental health, they do still have some limitations. Not everyone has access to technology through which the apps can be run, there are elements of data collection which may make some users uncomfortable, there is not much regulation of these mental health services, and the apps may turn people away from using harder to access but more provenly effective services that they could benefit from.

Legal Services

Legal services supervise the involuntary commitment or outpatient commitment of those judged to have mental disorders and to be a danger to themselves or others. Some legal organisations provide specialised services for those diagnosed with mental disorders who may be challenging discrimination or involuntary commitment.

Mental health courts are specialised court dockets that provide community treatment and supervision in lieu of incarceration for criminal offenders with mental illness. A judge assesses the defendant’s background as well as the influence of his or her mental disorder on the committed crime. A team of mental health professionals and legal advisors ensures that a particular mental health treatment programme provides appropriate opportunities for rehabilitation and prevent future criminal behaviour. The defendant is given the choice to decide if they want to participate in the treatment, unless they are unable to provide informed consent. In such cases, a conservator could make treatment decisions on behalf of the defendant and may give permission to use medications, if appropriate. Successful completion of the programme may result in reduced sentences or all charges against the defendant to be dropped.

Global Situation

Statistics

In 2017, more than 970 million or 1-in-7 individuals were purported to have one or more mental or substance use disorder(s). Anxiety and depressive disorders were, by far, the most attributed. Moreover, around 5%, and up to 12%, of global disease burden was attributable to mental or substance use disorders. Countries that have the greatest disease burden from mental or substance use disorders include Kuwait, Qatar, Australia, among others.

A Global Mental Health Group in coordination with the World Health Organisation has called for an urgent scaling up of the funding, staffing and coverage of services for mental disorders in all countries, especially in low-income and middle-income countries.

According to the Recovery model, services must always support an individual’s personal journey of recovery and independence, and a person may or may not need services at any particular time, or at all. The UK is moving towards paying mental health providers by the outcome results that their services achieve.

Traditional and Alternative Services

Traditional healing centres are popular worldwide and provide accessible mental health services for the native population. This community-based practice is led by folk healers, who use herbal remedies, spiritual rituals, and indigenous perspectives to provide comfort for individuals. These services are highly culture-specific and, therefore, its structure varies across the globe. Traditional healing approaches are sometimes used alongside conventional or western medicine.

In addition, each country has its own view on mental health disorders. While many nations share advocacy for mental health, there are still several countries that stigmatize medical or behavioural treatment for these disease states. Examples of these are Canada and China, such that both have high mental health illness rates but low utilisation rates of mental health services. While the cause of this is unknown, it is believed to be due to general stigma in those communities towards seeking help for mental health.

Problems with Mental Health Services

Expanding Increase in Demand

As awareness of mental health increases more and more people require mental health services. According to studies in 2023 over half of adults (54.7%) suffering from a mental illness are not receiving treatment, and almost a 3rd (28.2%) of adults with mental illness cannot get the treatment they need. There is increasing demand for new paths to provide mental services such as telehealth to make the distribution of services more streamlined along with need for more service providers to account for growing demand for treatment.

Struggle to Provide Services for Underserved Communities

Service providers for mental health have long struggled to provide adequate care for underserved communities such as minorities, the homeless, and incarcerated populations. These groups generally are in need of greater amounts of care in part due to the adversities that have both created and perpetuated their situations like systemic racism, troubled backgrounds, access to housing, and poverty. There are barriers to access for mental health services that continue to make them inaccessible such as high cost, language barriers, and access to providers in many communities.

Systemic Barriers

Many governments across the globe continue to neglect the importance of mental health services. The United States for example continues to not provide healthcare accommodation for mental health services and struggles to fulfil policies like The Mental Health and Addiction Parity Act of 2008 that are intended to make mental health services more accessible. Many governments continue to fail to recognise mental health services as important facets of healthcare and properly provide for them. Many countries still consider mental health a problem of which only high earning countries face and fail to recognize mental health as a developing struggle that affects people of all backgrounds.

Push Toward Change

There is an increasing push for new innovative ways to provide mental health services. Telehealth has been a massively eye opening success following its widespread usage during the 2019-2020 COVID-19 Pandemic and has changed the belief that mental health services cannot be useful when provided electronically. Suggestions such as governmental change and the creation of workers who bring mental health services to hard to reach communities and individuals have been theorised to be possible solutions. Apps for psychological services are also looked at as a promising new development that could greatly expand people’s access to psychological services in the future due to their numerous benefits such as convenience, anonymity, and outreach.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Services_for_mental_disorders >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

From the Front Lines to the Fight for Sobriety: The Battle Against Alcohol Addiction Among Veterans

Published on by Andrew MarshallLeave a comment

Introduction

In the aftermath of their service, many veterans face many challenges as they reintegrate into civilian life. Among the most pressing and often overlooked of these challenges is alcohol addiction. The reasons behind this are complex and multifaceted, involving psychological, social, and physiological factors. As we delve into this pressing issue, it is crucial to understand not just the prevalence of alcohol use among veterans but also the underlying causes and the paths toward recovery.

Understanding the Scope of the Issue

Alcohol addiction impacts a significant number of military veterans. Studies reveal that the rates of heavy drinking and alcohol use disorders (AUD) are notably higher among veterans compared to their civilian counterparts. The transition from military to civilian life can often be turbulent, marked by a loss of camaraderie and structure that the military environment provides. This can lead to feelings of isolation, depression, and anxiety, which some veterans may attempt to manage or mitigate through increased alcohol consumption.

The gravity of this issue is underscored by its consequences, which range from deteriorating physical health to strained family relationships and decreased quality of life. Addressing alcohol addiction in veterans is not just about treating the addiction itself but also about understanding and addressing the broader context of their mental health needs.

Why Veterans Struggle with Addiction


The root causes of why veterans struggle with addiction are deep and diverse. For many, the experiences of combat and the stress of deployments can leave lasting psychological scars, manifesting as post-traumatic stress disorder (PTSD) or other mental health disorders. Alcohol often becomes a coping mechanism to dull the pain of these memories and the stress of adjustment.

The military culture, which sometimes normalises drinking as a way to build camaraderie and unwind, can also play a role. This normalisation can make it difficult for veterans to recognise the onset of dependency. Additionally, the stigma associated with seeking help for mental health issues can prevent many from accessing the support they need, allowing the cycle of addiction to deepen.

A Pathway to Healing: Veterans Alcohol Rehab


Addressing alcohol addiction among veterans requires specialised approaches that cater to their unique experiences and needs. Thankfully, there are veterans alcohol rehab facilities that understand their unique needs, offering tailored treatment programmes that integrate mental health support with addiction recovery.

Such facilities are designed to provide a supportive environment where veterans can heal among peers who understand their specific struggles. These centres often employ therapies that address both PTSD and substance use disorders, acknowledging the interlinked nature of these issues. The treatment programmes may include cognitive-behavioural therapy, group sessions, and activities designed to rebuild the sense of camaraderie and support that many veterans miss after leaving the military.

Creating Sustainable Support Systems


While specialised treatment is critical, the recovery journey does not end when a veteran leaves a rehab facility. Sustainable support systems are vital for long-term recovery. This involves continuous care approaches, such as ongoing counselling and support groups specifically for veterans, that can provide ongoing encouragement and relapse prevention.

Community-based programmes that encourage social reintegration and the rebuilding of relationships can also play a crucial role. Many veterans benefit from peer support networks where they can share experiences and solutions in a non-judgemental space. Additionally, family therapy and education can equip loved ones with the tools needed to effectively support the veteran’s recovery journey.

Raising Awareness and Advocacy Efforts

Raising awareness is crucial in the battle against alcohol addiction in veterans. Advocacy efforts focus on educating the public and policymakers about the unique challenges veterans face and the critical need for comprehensive support services. These initiatives strive to foster a greater understanding and generate funding for more effective programmes. Advocacy also plays a key role in pushing for policy changes that improve care accessibility and quality for veterans struggling with addiction. By highlighting success stories and the positive impacts of specialised rehab facilities, advocates can inspire community involvement and enhance the support systems surrounding our veterans. These concerted efforts ensure that veterans do not fight this battle alone but are supported by a community committed to their health and well-being.

Summary

The fight against alcohol addiction among veterans is not just a personal battle; it is a community and societal imperative. By increasing awareness, reducing stigma, and enhancing access to specialised care, we can provide our veterans with the support they need to overcome addiction and lead fulfilling lives. This is not merely a health issue – it is a crucial aspect of honouring and supporting those who have served our country.