362 (See OHCM p374) y r t a h c y s P i Barbiturate withdrawal may cause seizures death; withdraw as an in- patient ( \205\223 o f the previous daily dose as phenobarbital; lower the dose over 2wks). 363 Alcohol-related problems Alcohol causes as much harm as smoking and hypertension. Abuse imp lies that repeated drinking harms a person \200\231s work or social life. Addiction implies : \200 Diffi culty or failure of abstinence \200 Narrowing of drinking repertoire \200 Increased tolerance to alcohol See p513 for prevention Often aware of compulsion to drink \200 Priority is to maintain alcohol intake \200 Swe ats, nausea, or tremor on withdrawal. Ask about tolerance, worry about drinking, \200\230eye opener \200\231 drinks used in the mornings, amnesia from alcohol use, and attempts to cut down. 2 points is TWEAK +ve (?more sensitive than CAGE questions).319,320 Alcohol & organ damage Liver: (normal in 50% of alco holics). Fatty liver: Acute, reversible; hepatitis; 80% progress to cirrhosis (liver failur e in 10%) Cirrhosis: 5yr survival 48% if alcohol intake continues (if it stops, 77%). CNS: Poor memory/cognition; cortical/cerebellar atrophy; retrobulbar neurop- athy; \201 ts; fa lls; accidents; neuropathy; Korsakoff \200\231s/Wernicke \200\231s encephalopathy (OHCM p7 28; \200 urgent parenteral vitamins are needed). Gut: D&V; peptic ulcer; erosions; varices ; pancreatitis. Marrow: Hb \200\201; MCV \200\200. Heart: Arrhythmias; BP \200\200; cardiom yopathy; fewer MIs (?bene \201 t only if \200\20655yrs). Skeleton: Heavy drinking disrupt s calcium metabolism (osteoporosis risk \200\200).321 Sperm: Fertility \200\201; sperm moti lity \200\201 (in 34 precisely analyzed medical students).322 Malignancy: GI & breast. Soci al: Alcohol is related to violent crime and suicide. In medical students, alcohol correlate s with events such as missing study, sexually escapades, \201 sticuff s, etc323 n=194 \200 and \200 students are equally prone to use alcohol at high doses to relieve stress (this carries on into later years).324 Alcohol and drug levels Regular heavy drinking induc es hepatic enzymes; binging inhibits enzymes; it \200\231s probably not a good idea to indu lge in both and hope for the best. Be alert with phenytoin, warfarin, tolbutamide, etc. NB: par- acetamol may cause \200\200N-acetyl-p-benzoquinoneimine (it is hepatotoxic). Withdra wal signs (Delirium tremens) Pulse \200\200; BP \200\201; tremor; \201 ts; visual or tact ile hallucinations, eg of insects crawling under the skin (formication). \201\227: \200 Admit; monitor vital signs (beware BP \200\201). \200 For the 1st 3 days give diazepam ge nerously, eg 10mg/6h PO or PR if vomiting \200\224or IVI during \201 ts; chlordiazepox- i de is an alternative. After a few days, \200\201diazepam (eg 10mg/8h PO from day 4 \200 \2236, then 5mg/12h PO for 2 more days). \200 -blockers, clonidine, carbamazepine, and neu roleptics (if no liver damage) are adjuncts (not advised as monotherapy).325 Treatment Does the patient want to change? If so, be optimistic, and aug- ment his will to do so. Should abstinence or controlled intake be the aim? If the former, remarkable recovery of organs (e g hippocampus) is possible.326 Treat coexisting depression (p336). Refer to specialists. Se lf-help/group ther- apy (Alcoholics Anonymous) help, drugs which produce a nasty reactio n if alcohol is taken (disul \201 ram 200mg/24h PO). Reducing the pleasure that alco- hol brings (and craving on withdrawal) with naltrexone 25 \200\22350mg/24h PO (an opioid recept or antagonist) can halve relapse rates.327 N=111 SE: vomiting, drowsi- ness, dizziness, joi nt pain. CI: hepatitis; liver failure; monitor LFT. Get expert help. Acamprosate (OHCM p445 ) can treble abstinence rates. CI: pregnancy, severe liver failure, creatinine >120 mol/L; SE: D&V, libido \200\200 or \200\201; dose example: 666mg/8h PO if >60kg and <65yrs old. Economic analysis supports its use, at least in some communities.328 Non-drug, physician-b ased brief interventions for problem drinkers: (Edu- cation, counseling, goal-setting + mon itoring of \200 GT in those who have social or physical problems from alcohol, but who do not exhibit full dependency.) 50% of trials show that \200 GT falls in the intervention gr oup, but none show clear improvement in alcohol-related morbidity. More costly regimens far e no better. Homelessness is common; help with housing & rent, problem-solving, commu- nica tion, drink refusal, and goal setting can help this desperate problem.329 y r t a i h c y s P N=448 N=114 Intellectual disability and learning disabilities330 De \201 nition Below-average general intellectual functioning which originated during the development period and is associated w ith impairment in adaptive behavior (Heber 1981). People with learning dif \201 culties ar e at \200\200risk for men- tal illness. Four subtypes: Mild (IQ 50 \200\22370): Accounts f or 80% of people with learning disabilities. There is useful development of language, and l earning dif- \201 culty only emerges as schooling gets under way. Most can lead an indepe nd- ent life. Moderate (IQ 35 \200\22349): most can talk and \201 nd their way about Seve re (IQ 20 \200\22334) limited social activity is possible. Profound (IQ <20): simple speech may be unachievable. Special schooling and medical services are needed, as is adequate car e and counseling for the families involved. In the UK, lack of resources and ambiguous comm unity responsibilities are big problems.331 Fur- ther information: ask MENCAP (tel.uk 020 7 454 0454).332 Epidemiology 27 per 1000 (80% have IQ 50 \200\22370). People with learning di ffi cul- ties are at \200\200risk for mental illness compared to the general population. T he Patient Physical: Sensory and motor disabilities, epilepsy, incontinence. Psychiatric: A ll psychiatric disorders can occur but the presentation is modi- \201 ed by low intellige nce. In the diagnosis of psychiatric disorder, emphasis is given to the behavioral manifest ation of the disorder. Causes Physical causes are found in 55 \200\22375% of severely learn ing disabled in- dividuals. Chromosomal abnormalities: Down \200\231s syndrome, fragile X s yndrome p648. Antenatal causes: Infections, alcohol, hypoxia, nutritional growth retar- dat ion, hypothyroidism. Perinatal causes: Cerebral palsy. Post-natal causes: Injury, infection s, impoverished environment. Forensic issues Arson and sexual off ences (usually exhibition ism in males or, more rarely, \200\230public disrobing \200\231 in women)333 are examples of off ences. Care is needed in questioning learning-disabled people about an alleged off e nce, due to increased suggestibility and risk of making false confessions. Treat- ment may center on issues of accepting that the off ence took place, the taking responsibility for o ff ences, accepting the intention of the off ending behavior, and on victim awareness.334 B ehavioral approaches might focus on masturba- tory satiation, covert sensitization, and sti mulus control procedures.335 Assessing learning-disabled people \200 Cause(s) of the lear ning disability \200 Associated medical conditions \200 Intellectual and social skills development \200 Psychological and social functioning \200 Dialog with and support for carers. Care of people with learning disability \200 Prevention and early detection is th e aim \200\224as is care in generic (eg NHS) services (minimized specialist care) un- less there are complex physical, emotional and behavioral issues.336 \200 Regu- lar assessment of attainments and disabilities \200 Advice, support, and help for families \200\224eg t eaching parents how to be better \200\230tutors \200\231 can help337 \200 Arrange specia l needs teaching at school and training/occupation \200 Housing and social support to ena ble self-care \200 Medical, nursing, and other services, as outpa- tients, day patients, or inpatients \200 Psychiatric and psychological services usu- ally from a community-base d multidisciplinary team. Treatment of psychiatric disorders \200 Side eff ects of medica tion may not be apparent as learning-disabled patient may not be able to draw attention to them \200 Antipsychotics can lower seizure threshold and patients with learning disabilit y are more likely to get seizures \200 Behavioral therapy is widely used. 364 y r t a h c y s P i 365 Human rights for those with learning diffi culties The 14 speci \201 c rights below must b e taken in the context of general psychi- atric rights:338 \200\226To have a professional skilled in dealing with your condition \200\226To receive treatment based on sound evidenc e \200\226To have treatment in a setting which is decent, humane, and non-abusive \200 \226Regimes must promote a ful \201 lling social life \200\226Active participation in all decisions taken about care. 1 Ensure full assessment within the context of joint strategic needs as- sessment by Social Services, GPs, and other professionals fully trained in \200 \230partnership working \200\231. . o s e v e i l e b 2 Include the person in all decisions aff ecting him or her. 3 Promote enriching activity t o counter idle humdrum impoverished living. 4 Listen to concerns of both the person and the ir carer. 5 Derive personalized care plans via dialog with the person and carer(s). 6 Expla in what the options are, ideally in terms that he/she understands. 7 Help him or her decide from a de \201 ned list of genuine choices. 8 Don \200\231t hurry through consultations \200\234to get back to normal people \200\235; spend more time; go slowly. Not being able t o give a good history doesn \200\231t mean you can skip this bit: it means you must use oth er methods to get the information, eg discussions with carers or direct observation. e w f i s r o t c o d y r t a i h c y s P r e t t e b e r a e W ? e u l a v 9 Don \200\231t be pleased because they are not complaining of anything. No re- ported symp toms and no complaints about circumstances does not let you off the hook! You may need to i nsist to carers that a nasty but appar- ently painless ulcer be treated \200\224or that a \201 re-escape be unblocked.etc etc l a u q e 10 Check for physical illnesses which may otherwise go unreported. 11 Watch for neglect/abu se from well-meaning under-trained over-worked staff (who may desperately crave your suppor t and encouragement).339 12 Don \200\231t reach too readily for drugs to curb behavior. Con sider all options. 13 Be aware of local authority Protection of Vulnerable Adults protocols . 14 No tokenism! (paying lip service to the above without intending change). f o s e v i l l l a e r A Personality disorders and psychopathy Personality comprises lasting characteristics which m ake us who we are: easygoing or anxious; optimistic or pessimistic; placid or histrionic; a mbitious or stay-at-home; fearless or timid; self-deprecatory or narcissistic1 (self-love, founded on a grandiose belief in one \200\231s unique superiority).340 Personality can chan ge and develop quite quickly, eg after religious conversion in which a timid man is remolde d into a fearless activist. Personality is a spectrum lying between the above opposites. St atistical analysis reveals that all these distinc- tions overlap, and are describable in te rms of a few orthogonal dimensions (eg neuroticism/psychoticism; introvert/extrovert). Thos e with abnormal person- alities are de \201 ned as occupying the extremes of the spectrum. Abnormal per- sonality only matters if it is maladaptive, causing suff ering either to its posses- sor or his associates. In general, psychological symptoms which are part of a pers onality disorder are harder to treat than those arising from other causes. DSM-IV classi \201 cation of personality disorders341 Cluster Description A B 366 \200 Disorder Paranoid; schizoid; schizotypal (p323) Antisocial (psychopathic); Borderline; hist rionic; narcissistic1 Odd or eccentric behavior Dramatic or emotional behavior Anxious or avoidant behavior Avoid ant; dependent; obsessive \200\223compulsive C y r t a h c y s P Psychopathy \200\230He dislikes showing his feelings, and he \200\231d rather be cruel tha n put his real feelings into words \200 he doesn \200\231t care for anyone and perhaps he n ever will \200\231. So says Dostoevsky; lesser psychologists dwell on reckless, anti social acts, impulsivity, lack of guilt social and legal nonconformity. Dostoevsky \200\231s d e \201 nition lasts because of its brevity \200\224and that telling word perhaps. Can we c hange? What must change before psychopaths can love? This perhaps blowing in from 19th-cent ury Russia sends a shiver down our 21st-century spines: perhaps all the psychopaths we lock up might be able to change. What needs to be unlocked? Read Crime and Punishment to \201 nd out. i Treatment is problematic unless there is a strong will to change. Peer pres- sure/group the rapy (p376) may motivate. It is rarely wise to use drugs, but there is evidence that SSRIs (p341) may help aggressive personality disorder. Borderline personality disorder There is u nstable aff ect regulation, poor impulse control, and poor interpersonal relationships/self -image, eg with re- peated self-injury, suicidality, and a diffi cult life-course trajector y.342 Associ- ations: ADHD;2 learning diffi culties. Genetics and adverse childhood events (eg abuse) are predispositions. Intervene (and refer) early with speci \201 c manage- ment plan, addressing work, Dialectical behavior therapy, inpatient hospital programs, and drug s can reduce depression, anxiety, and impulsive aggres- sion. Eventually, supportive interp ersonal dyads are achievable. \200 2011 Other personalities Obsessional personality: The rigid, obstinate bigot who is preoccupied with unimportant (or vital) detail. Emotionally u nstable personality: Tendency to form intense relationships and rapid \202 uctuations in mood, with impulsivity. Histrionic personality: The self-centered, sexually provocative (bu t frigid) person who enjoys (but does not feel) angry scenes. Schizoid personality: Cold, a loof, introspective, misanthropic.343 1 Narcissus was the 1st celebrity to be famous just for being beautiful. He carelessly spur ned all lovers, including Echo. Morti \201 ed by his callousness, all but her voice was co nsumed by grief. This disembodied voice now repeats for us the 3 cardinal facts about narci ssists: 1 They never understand others. 2 Loving a narcissist is a recipe for death. 3 If y ou manage to escape death, your narcissistic lover may blame you for his death; analysis of suicide notes reveals a class of suicides whose \201 nal act is to blame their lovers.34 4 To help these characters outgrow narcissistic resentments, we may confront their illusion s. This is powerful but dangerous. Narcissus discovered the torment of unrequited love only after falling in love with his own image as glimpsed in a pool. As often as he stoops to k iss it, so it fragments and vanishes. Dying of love- sickness, he gains insight into others \200\231 pain, whereupon he morphs into a handsome daff odil with a superb scent, which, t o this day, blows to us each spring from Arcadia. See Ovid & J Holmes Narcissism Icon Books 345 367 The anatomy of psychopathy Psychopathy seems to entail a genetically driven diff erence in connectivity (via the uncinate fasciculus) between the parts of the brain driving empa- thy , conscience (free will, or rather free won \200\231t) and impulse control (the orbito-pref rontal regions). It is not a fault necessarily, or a disease, or al- ways a disadvantage (l ook at medical hierarchies!). This has serious ethical and legal implications, eg a defense of \200\234my brain made me do it \200\235.346 s h t a p o h c y s p s a s r D Managing dangerous psychopathy: beyond medicine and the law People with dangerous and sever e personality disorder (DSPD3) and peo- ple with other psychopathic features form the bulk of forensic psychiatry. Therapeutic psychiatry is sometimes unfairly criticized for abandon ing psy- chopaths \200\224as if they were too much trouble. This easy criticism does not ta ke into account civil liberties: patients must either want treatment, or they must have a t reatable mental illness before they can be detained. Renewable sentences and protective cus tody? It is against this back- ground that the suggestion has arisen that those with a hist ory of psy- chopathic violence should receive care outside penal and health set-ups. Howeve r, this is no guarantee against injustice: for example, a man with- out psychopathy who poi soned his wife might be free to marry again af- ter 12 years in prison, but a man with psyc hopathy who had held hostages without harming them might never be free to rebuild his life. Hence con- siderations of natural justice make renewable sentencing hazardous.341 y r t a i h c y s P ? e r a c d e r t n e c - t n e i t a p n o d n a b a Methods of trying to treat DSPD include cognitive therapy and anti-libin- inal drugs (not a lways amounting to chemical castration). 4 NB: DSPD units at Broadmoor and Rampton hospital s have not chalked up successes match- ing their huge expense. Prof Peter Tyrer; 2010 As a leading DSPD psychotherapist says: \200\234The only way that somebody with personality dis order is going to make progress is through their own eff orts. They can be helped by profes sionals, but nobody else can do it for them in terms of arriving at that understand- ing of their own responsibility for what \200\231s happened. \200\235Tony Maden;2010 e w d l u o h s n e h W tinyurl.com/yeyvyyk When patients \200\231 requests for anti-libidinal drugs4 may be valid \200 Hyperarousal (frequent sexual rumination/preoccupation, diffi culties in . e d i c i u s o t d a e l s n o i t c e j n i d e c r o f n E controlling sexual arousal, high levels of sexual behavior). Intrusive sexual fantasies or urges. \200 Dangerous paraphilias (sadism; necrophilia). Hi ghly repetitive paraphilic off ending such as voyeurism or exhibitionism may also respond t o drugs. In the context of an off ender in the community, the off ender \200\231s manager m ust get prior authority to use anti-libidinal medication, and request the off ender \200 \231s GP to refer the off ender to the \200\230approved psychiatrist \200\231. 2 Attention de \201 cit hyperactivity disorder (ADHD, p212) is increasingly recognized in adults, often with oppositional de \201 ant disorder. Exercise regimens and methylphenidat e may help.347 3 DSPD: give something an acronym and it half exists. Add an NNT ( 5!) and t he trick is done; we rush to memorize, categorize and research it. To study its causes perh aps we should confront our imagined worlds of myth, language, legalisms, and pure and impur e invention, rather than value- free biological or mental health categories. But to be thor oughly skeptical about this skepticism: show us any value-free construct. 4 Antilibidinal d rugs may \200\201testosterone to young-boy levels \200\224but risk liver damage, breast gr owth, hot \202 ushes, depression and \200\201bone density, eg oral cyproterone acetate ( Androcur ). Long-acting drugs (leuprolide, goserelin, triptorelin) can be injected and may be better. SSRIs are sometimes used (unreliably) to \200\201 libido and sexual preoccupat ion and compulsive re-off ending. Withdrawal of psychotropic drugs Withdrawing benzodiazepines \200\207The withdrawal syndro me may well be worse than the condition for which the drug was originally prescribed. So tr y to avoid benzodiazepine use, eg relaxation techniques for anxiety, or, for insomnia, a du ll book, sexual intercourse, and avoiding night-time coff ee may facilitate sleep. If not, limit hypnotics to alternate nights. 368 30% of those on benzodiazepines for 6 months experience withdrawal symp- toms if treatment is stopped, and some will do so after only a few weeks of treatment. Symptoms appear sooner with rapidly eliminated benzodiazepines (eg lorazepam vs diazepam or chlordiazepoxide). It is not possible to predict which patients will become dependent, but \200\230passive depe ndent \200\231 or neurotic personality is partly predictive. Symptoms often start with anxi ety or psy- chotic symptoms 1 \200\2232 weeks after withdrawal, followed by many months of gradually decreasing symptoms, such as insomnia, hyperactivity, panic, agora- phobia, and d epression. Irritability, rage, feelings of unreality and depersonali- zation (p334, p346) a re common; hallucinations less so. Multiple sclerosis may be misdiagnosed as there may be d iplopia, paraesthesiae, fasciculation, and ataxia. Gut symptoms include D&V, abdominal pain , and dysphagia. There may also be palpitations, \202 ushing, and hyperventilation sympto ms. The problem is not so much how to stop benzodiazepine treatment, but how to avoid being manipulated into prescribing them unnecessarily. This is addressed on p330. How to withdra w: \200 Augment the patient \200\231s will to give up (stress disadvan- tages of continuo us \200\224). \200 Withdrawal is harder for short-acting benzodiaz- epines, so change to diazepam. \200 Agree a contract to prescribe a weekly sup- ply, and not to add to this i f it is used up early. \200 Withdraw by 2mg/week of diazepam. Warn to expect withdrawal symptoms, and not to be alarmed. Withdrawing antidepressants: All antidepres- sants may cau se a discontinuation syndrome. Distinguish between this and withdrawal symp- toms (implies addiction). Patients often worry that they may get hooked on antidepressants which can aff ect compliance. Discontinuation symptoms are explained by the theory of recep- tor rebound, eg an antidepressant with potent anticholinergic eff ects may be associated with diarrhea on withdrawal,349 30% get the syn- drome and it may mimic the original symptoms of the ill ness.350 Withdrawal is best over \200\2064 weeks unless \202 uoxetine is co-pre- scribed (it has a long t , so no withdrawal regimen is needed, and it also helps reduce symptoms, see BOX).351 Discontinuation symptoms \200 Onset is within 5 days of stopping, sometime s after cross-tapering or missing doses. Usually mild and self-limiting but can be prolonge d and severe ( \200\234a dark frightening tunnel \200 I was that frayed I \200\231d have ki lled \200\235).348 Some symptoms are more likely with certain drugs. MAOIS: Com- mon: \200 Agitation, irritability, ataxia, movement disorders, insomnia, cognition \200\201, slowed or pressured speech. Occasionally: \200 Hallucinations, paranoid delusions. The most tro ublesome MAOIs: tranylcypromine, when metabolized, has am- phetamine-like properties so can have true withdrawal syndrome. Tricyclics: Common: \200 \200\231Flu symptoms; insomnia; \200\200dreaming. Rarer: \200 Movement disorders; mania; arrhythmias. The most troubleso me tricyclics: amitriptyline; imipra- mine. SSRIs: Common: \200 \200\231Flu-like symptoms ; headaches; nasty shock-like sensa- tions;352 dizziness; insomnia; tears/irritability/fury ; vivid dreams. Occasionally: \200 Movement disorders; poor concentration/memory; deliriu m. The most trou- blesome SSRIs: Paroxetine; venlafaxine (both have short half-lives). \200\207Consider stopping alcohol before starting withdrawal, and starting meditation and a n exercise program.348,353 Tell friends \200\234I won \200\231t be myself for a while. \200\235 y r t a h c y s P i Fluoxetine may help with- drawal from paroxetine \200 Days 1 \200\2233: 30mg paroxetine + 10mg \202 uoxetine Day 4: 20mg paroxetine+ 20mg \202 uoxetine Day 5: 10mg paroxetine + 20mg \202 uoxetine Days 6 \200\2239: 0mg paroxetine + 20mg \202 uoxetine Then stop \202 uoxetine.348 369 Swapping antidepressants: how to cross-taper When an antidepressant has failed to work at a n adequate dose, or is poor- ly tolerated, changing drug is appropriate. Avoid abrupt withd rawal when swapping antidepressants; cross-tapering is preferred. Speed of cross-ta- pering is best judged by patient tolerability. NB: co-administration of some anti-depressants is absolutely contraindicated, see below \200\224dangers include precipitating the serotonin s yndrome354 (restlessness; diaphoresis, ie exces- sive sweating); tremor; shivering; myoclon us; confusion; convulsions; death). Example of cross-tapering based on the Maudsley regimen 355 Week 1 100mg/24h Week 2 50mg/24h Week 3 25mg/24h Week 4 Nil Withdrawing amitriptyline from 150mg/24h Introducing sertraline y r t a i h c y s P 25mg/24h 50mg/24h 75mg/24h 100mg/24h Cautions When swapping from MAOIs or tranylcypromine to any other anti- depressant, withdra w and wait for 2 weeks (the time taken for monoamine oxidase to be replenished); for moclob emide wait 24h. Do not co-administer clomipramine and SSRIs or venlafaxine. Beware \202 u oxetine interactions (may still occur for 5 weeks after stopping, due to long half-life). Introducing the psychotherapies1 370 \200 As usual, it was dialog that combed out my muddle.Arthur Miller Medicine has three great br anches: prevention, curing by technical means, and healing \200\224and psychotherapy is the embodiment of healing: a holistic ap- proach in which systematic human dialog becomes a hu manizing enterprise for the relief of suff ering and the advancement of self-esteem. Questi ons such as \200\234What is the meaning of my life \200\235 and \200\234what is signi \201 cant? \200\235 are answered in a diff erent way after exposure to a gifted psychothera pist. Changes occur in cognition, feelings, and behavior. This is why psychotherapy is dang erous and exciting: it changes people. Hence the need for supervision and ongoing train- in g and self-awareness on the part of the therapist. Timebends 88 Psychotherapy stands in stark contrast to the increasingly questioned technical, machine-ba sed realm of medicine, and we accord it great promi- nence here, in the hope that our expli cit descriptions, and their reverberations throughout our books will produce corresponding reverberations in our minds and in our daily work in any branch of medicine, to remind us t hat we are not machines delivering care according to automated formulas, but humans deal- i ng with other humans. So, taken in this way, psychotherapy is the essence of psychiatry \200\224and the essence of all psychotherapy is communication. The \201 rst step in commu nication is to open a channel. The vital role that listening plays has already been emphasi zed (p320). y r t a h c y s P i It is not possible to teach the skills required for psychotherapy in a book, any more than it is possible to teach the art of painting in oils from a book. So what follows here (p372 \200\2235) is a highly selective tour round the gallery of psychotherapy, in an attempt to show the range of skills needed, and to whet the reader \200\231s appetite. It is not envi saged that the reader will try out the more complicated techniques without appropriate supe rvision. The psychotherapies may be classi \201 ed \201 rst in terms of who is involved in the tr eatment sessions: an individual, a couple, a family, or a whole group; and secondly they ma y be classi \201 ed by their content and methods used: analytic, interpersonal, cognitive, behavioral. Behavioral therapies (more details: p372) aim to change behavior, eg if avoidi ng crowded shops (agoraphobia) is the issue, a behavioral approach focuses on the avoidance -behavior. Such approaches will de \201 ne behavioral tasks that the patient is expected t o carry out between sessions. Cognitive therapy (p374) focuses on thoughts and assumptions, promulgat- ing the idea that we respond to cognitive representations of events, not to raw events alone. If this is so, cognitive change may be required to produce emotional and beh avioral change. So in the above example of agoraphobia, the therapist would encourage artic ulation of thoughts associated with enter- ing crowds. The patient might report that she be comes anxious that she might be about to faint \200\224fearing that everyone will think her a fool. These thoughts would be looked at using a Socratic approach: \200\234Have you in fact ever fainted? How likely would you be to faint? If someone fainted in front of you in a shop, what would you think? Are they foolish? \200\235 Long-term psychoanalytical therapi es (p382) are concerned with the ori- gin and meaning of symptoms. They are based on the vi ew that vulnerabil- ity arises from early experiences and unresolved issues, eg from childh ood. The therapist adopts a non-dominant stance, encouraging the patient to talk without in hibitions. The therapist encourages change by suggesting interpre- tations for the content of the patient \200\231s talk. Which psychotherapy is most successful? This is tackled on p 388. 1 Further reading: I Levi Basic Notes in Psychotherapy, Petroc Press ISBN 1-900603-50-0 371 De \201 nitions of psychotherapy There are important diff erences in how people use the te rm psychotherapy. The \201 rst recorded de \201 nition states that Psychotherapy includes every description of therapeutics that cures by \200 intervention of the psychical functions of the sufferer.F Eeden 1892 Med Mag This de \201 nition is worth bearing in mind because, uniquely, it focuses on the content of the intervention made by the patient, not on the speci \201 cs of the therapist \200 \231s intervention. The most general modern de \201 nition, and the one em- ployed in this section, is summarized thus: Psychotherapy denotes treatment of mental disorders and behav- ioural disturbances using \200 support, suggestion, persuasion, re-educa- tion, reassurance, and insight in order to alter maladaptive patterns of coping, and to encourage personality growth.Dorland \200\231s Medi- cal Dictionary y r t a i h c y s P Some commentators draw a distinction between counseling and psycho- therapy \200\224but usi ng the above de \201 nition (or any de \201 nition that recognizes the great heterogeneit y of psychotherapy) no valid distinction can be made, un- less it is between the various ty pes of psychotherapy. The main issue to bear in mind is that psychotherapy can be more or l ess speci \201 c, and more or less involved in, and driven by, theory. So is \200\230just being nice to patients \200\231 in the course of one \200\231s medical activities an example of psychotherapy at work? The answer is \200\230no \200\231 \200\224 not because being nice is therapeutically neutral, but because one \200\231s attention is n ot focused on planning change through the systematic use of interpersonal techniques. The issue of training is very important, and here are some questions that might usefully be addressed to anyone off ering psychotherapy: 1 Is there proof of effi cac y? Ask for evidence of long-term results. 2 What quali \201 cations does the therapist hol d? Is he or she supervised? 3 Is the recommended regimen tailored to the patient \200\231s unique needs? 4 How will progress be monitored? 5 Is con \201 dentiality assured? 6 Is the re support and follow-up after the formal program ends? \201\201Fig 1. Inside the speech-bubble: The therapist is precariously supported by a trip od of con \201 dentiality, training and peer-based supervision. The couch hardly ever exists in practice, but it stands for a place where anything can happen \200\224where we sit side- by- side with our shadow selves and hear the stuff of dreams, nightmares, and realities, un - cushioned by workaday self-deceptions. It contains its own labyrinth. Miriam Longmore Behavioral therapy Behavioral therapy aims to change a person \200\231s behavior using one of several techniques depending on the condition. When used in conjunction with cogni- tive therapies (see p374) the term cognitive-behavioral therapy is used (CBT). Exposure/ \202 ooding/implosion Indication: Phobias. Technique: \200 The anxie- ty-provoking object or s ituation is presented in vivo or in imagination (pro- longed in vivo in \202 ooding). \200 Implosion involves imagined exposure to stimuli in a non-graded manner. \200 The pa tient then stays with the anxiety-provoking stimuli until there is habituation (ie he becom es accustomed to the anxiety by frequent exposure), and the avoidance response is extinguis hed. Relaxation training Indication: Mild/moderate anxiety. Technique: \200 A sys- tem of exercises & regular breathing to progressively relax individual muscle groups. Aim to achi eve relaxation in all postures: recumbency is easiest (?from \200\201baroreceptor load).35 6 \200 Link the relaxed state with pleasant, imagined scenes so that relaxation can be in duced by recalling the imagined scene. Systematic desensitization Indications: Phobic disor ders. Technique: Pa- tients form a hierarchy of fears about the phobic stimulus. Therapy us es graded exposure (least fearsome \201 rst) to real Wolpe 357 while patients perform rel axation or imagined stimuli,Joseph techniques until anxiety is extinguished. It is ethicall y less controversial than \202 ooding358 as progress up the hierarchy is only when patien ts are completely comfortable with the cur- rent level; eg \201 g 1 can be preceded by an almost neutral image, such as \201\203.359 Response prevention Technique: \200 Involves exposure to an anxiety-provok- ing stimulus (eg a toilet seat for patients fearing contami nation). \200 The patient is subsequently prevented from carrying out the usual compulsiv e behavior or ritual until the urge to do so has passed Indications: Obsessions. Thought st opping Technique: The patient is asked to ruminate and then taught to interrupt the obsessi onal thoughts by arranging a sudden intrusion, eg snapping an elastic band on the wrist. In dications: \200 Obsessional thoughts occurring without compulsive rituals. \200 Undesir ed sexually deviant thoughts. Aversion therapy/covert sensitization Technique: \200 Avers ive therapy involves producing an unpleasant sensation in the patient in association with a n aversive or noxious stimulus (eg electric shocks, chemically induced nau- sea, pain) with the aim of eliminating unwanted behavior. \200 Covert sensitiza- tion involves the use o f aversive stimuli in imagination (eg the approach of a policeman to arrest him/her for his /her undesirable behavior). Indications: \200 Alcohol dependence syndrome (disul \201 ra m used to induce nausea if alcohol is consumed). \200 Sexual deviations. Cautions: \200 Punishment procedures are gener- ally ineff ective unless patients are taught more appropr iate behaviors. Social skills training Technique: \200 Aims to modify a patient \200\231s social behav- iour in order to help overcome diffi culties in forming/maintaining relation - ships. \200 Video is used to de \201 ne and rate elements of a patient \200\231s behav ior in standard social encounters \200 The patient is then taught more appropriate behavi or by a combination of direct instruction, modeling, video-feedback and role play. Indicati ons: Patients with social de \201 cits due to a psychiatric disorder. Token economy Techni que: Positive reinforcement improves behavior: tokens are given when desirable behavior is displayed. These can later be exchanged for goods or privileges. Indications: \200 Childr en (p210) \200 Learning disabled patients \200 Addictive disorders \200 Chronic psych iatric disorders. Prob- lems: \200 Patients become mercenary as they only behave well in exchange for tokens. \200 It does not prepare people for a world where rewards are subtle and delayed. 372 y r t a h c y s P i Fig 1.366 JML. Modeling and role play Technique: The acquisition of new behaviors by the process of imitat ion. Indications: Lack of social skills and assertiveness. Behavior therapy in impulse cont rol disorders (sex, shopping, gambling) Hypersexuality after brain injury: Examples: two cl ients were troubled by inappropriate touching of the opposite sex, and a third involved exh ibition- ism. In one case of touching, feedback was used to decrease inappropriate touching . In the other case of touching, scheduled massage was used to shift stimulus control to an appropriate setting. In the case of exhibitionism, a com- bination of self-monitoring, pri vate self-stimulation, and dating-skills train- ing were used to suppress the behavior.360 Behavior therapy also has a role in paraphilias such as voyeurism and masochism/sadism. It is controversial when consent is an issue (eg following a court \200\231s recommendation). 373 Cognitive elements can be added with the aim of minimizing self-deception y r t a i h c y s P regarding the eff ects of paraphilia behavior.361 Exposure response therapy is used eg in o bsessive-compulsive behavior (eg obsessive cleaning of some putatively contaminated object) . The therapist gradually exposes the client to contaminated objects, preventing the compul - sion by reducing anxiety about contamination, eg by breathing techniques. CBT (cognitive- behavior therapy) helps change how we think and hence how we feel. Fig 2 is a vicious circl e if thoughts are negative and lead to hos- tile, negative actions. By de \201 ning these relationships, CBT lets us see how th oughts and feelings interact; by changing thoughts, t he cycle is broken or turned into a virtuous cycle \200\224eg to prevent relapse after volu ntary abstinence vis- -vis impulse control disorders (eg bulimia). For purely cognitive th erapy, see p374. Fig 2. CBT. The abstinence violation effect (AVE) is a pivotal construct describing our cognitive and aff ective response to re- engaging in self- or court-prohibited behavior. AVE refers to the client \200\231s belief that abstinen ce, once broken, always leads to relapse ( \200\234Now I \200\231ve eaten one chocolate the whole box must go \200\224and I then I \200\231ll have to empty the fridge and now I \200 \231m on the slippery slope leading straight to the ice-cream in the freez- er \200 \200 \235). The false creation of an all-or-none requirement, loss of feeling of con- trol, and ensuing failure resulting in guilt, self-blame and lowered self-esteem can all be tackled b y cognitive-behavior therapy, eg by identifying high-risk situations and \200\230off ence precursors \200\231.362 These may be feeling lonely and rejected, after a break-up with a p artner \200\224or stress at work. In the case of pedophilia, CBT can be combined with group therapy and one way to confront pedophiles with the reality of their off ence yet which is helpful because it provides their \201 rst opportunity to express their feelings, sexual fantasies and thoughts about pedophilia.363 In general, the eff ects of cognitive-behavior al treatment for the most serious forensic inpatients (arson, violence, rape) are sometimes quite good in terms of oppositional-de \201 ant/egotistical behaviors \200\224and there a re also (unreliable) improvements in psychopathological symptoms, person- ality traits, and coping.364