der, and too severe to attribute to ordinary forgetfulness. Usually patchy and selective am nesia \200\224true global amnesia is rare. There is expectation of recovery and usually a h istory of recent traumatic event gradually emerges. One or more limbs or one side of the face or body may be The area of loss will cover the patient \200\231s beliefs about Memory loss, most often for recent events, not attributable 19_Semple_Chap19.indd 806 12/7/2012 4:30:29 PM CONVERSION (DISSOCIATIVE) DISORDERS 807 Here there is dissociative amnesia plus a history of travel Fugue outside the patient \200 \231s normal environs. The patient may \200\230come to \200\231 far from home, without mem ory of how they came to be there, and with a variable amnesia for other personal informatio n. Although there is amnesia for the period of fugue, the patient has apparently functioned normally during this time (e.g. able to buy travel tickets, etc.). Again recovery can be e xpected in time, and a history of recent traumatic events is commonly found. Diagnosis The diagnosis will usually be suspected due to the non- anatomical or clinically inconsistent nature of the signs. It is established by (1) excluding underlying organic dis ease, or demonstrating minor disorder insuf \201 cient to account for the symptoms; (2) \201 nding of \200\230positive signs \200\231 (i.e. demonstration of function thought to b e absent); (3) a convincing psycho- logical explanation for the de \201 cit. Additionally helpful though non-speci \201 c is a prior history of conversion symptoms or recurrent som atic complaints or disorder, family or individual stress and psychopathology (recent stress , grief, sexual abuse) or the presence of a symptom model. Treatment Clear presentation of diagnosis in collaboration with the treating medical team. Aim to present the diagnosis as positive (empha- sizing the likelihood of recovery) rather than negative ( \200\230we could n \200\231t \201 nd anything; it \200\231s all in your head \200\231). In general, avoid interventions which could maintain the sick role or prolong abnormal function (e.g. provisi on of crutches to those with dissociative gait disturbance) and instead consider interventi ons directed towards graceful resumption of normal function (e.g. physiotherapy). Treat psy chiatric comorbidity if present. Controlled treatment studies are absent, CBT, IPT, support ive psychotherapy, family therapy, biofeedback are all potentially helpful. Prognosis For a cute conversion symptoms, especially those with a clear precipitant, the prognosis is good, with expectation of complete resolu- tion of symptoms (70 \200\22390% resolution at follow -up). Poorer outcomes for longer-lasting and well-established symptoms. 19_Semple_Chap19.indd 807 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 808 Hypochondriasis Hypochondriasis is the preoccupation with the fear of having a serious dise ase which persists despite negative medical investigations and appro- priate reassurance wi th subsequent distress and impaired function. Clinical features The central and diagnostic clinical feature is the pre- occupation with the idea of having a serious medical condition , usually one which would lead to death or serious disability. The patient repeat- edly rum inates on this possibility and insigni \201 cant bodily abnormalities, normal variants, no rmal functions, and minor ailments will be interpreted as signs of serious disease. The pat ient consequently seeks medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations. The form of the belief is that of an over-valued idea; the patient may be able to accept th at their worries are groundless but nonetheless be unable to stop dwelling and acting on th em. Where the belief in illness is of delusional intensity, the patient should be treated a s for delusional disorder (b p. 220). Etiology As in somatization disorder there may be a h istory of child- hood illness, parental illness, or excess medical attention-seeking in the parents. Childhood sexual abuse and other emotional abuse or neglect are associated. In on e aetiological model, individuals with a combination of anxiety symptoms and predisposition to misattribute psychical symp- toms, seek medical advice. The resulting medical reassuran ce provides temporary relief of anxiety which acts as a \200\230reward \200\231 and makes further medical attention-seeking more likely. Epidemiology Equal sex incidence. Very varia ble prevalence depending on group studied (0.8% \200\22310.3%), higher in secondary care. D ifferential diagnosis The main differentiation is from the feared physical disease. In most cases this is straightforward, but the possibility of an early, insidious disease with vag ue physical signs and normal baseline investigations should be considered. Comorbidity High (>50%) incidence of generalized anxiety disorder. Hypochondriasis may also coexist with ma jor depressive illness, OCD, and panic disorder. Examination of the time course of symptom develop- ment and most prominent clinical features helps to distinguish primary hypochondri asis from a secondary clinical feature of these disorders. Management \200 Initial that symptoms with no structural basis are real and severe. Aim to plan continuing relationship and review, not contingent upon new symptoms. Explain negative tests and resis t the temptation to be drawn into further exploration. Patients will in the early stages of ten change or expand symptomatology. Emphasize aim to improve function. Break cycle of reas surance and repeat presentation \200\224family education may help in this. Allow patient time to ventilate their illness anxiet-ies. Clarify 19_Semple_Chap19.indd 808 12/7/2012 4:30:29 PM HYPOCHONDRIASIS 809 Pharmacological bene \201 t, even in the absence of depressive symptoms. Try \202 uoxeti ne 20mg, increasing to 60mg, or imipramine up to 150mg. Psychotherapy Behavioral therapy (r esponse prevention and exposure to illness cues); CBT (identify and challenge misinterpreta tions, substitution of realistic interpretation, graded exposure to illness-related situati ons, and modi \201 cation of core illness- beliefs), 75% symptom reduction in one controll ed trial.1 Uncontrolled trials demonstrate antidepressant 1 Warwick HM, Clark DM, Cobb AM, et al. (1996) A controlled trial of cognitive \200\223beha vioral treatment of hypochondriasis. Br J Psychiat 169: 189 \200\22395. 19_Semple_Chap19.indd 809 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 810 Body dysmorphic disorder The core clinical feature of body dysmorphic disorder is preoccupa - tion with the belief that some aspect of physical appearance is markedly abnormal, unattr active, or pathological. This preoccupation causes distress and has the characteristics of an over-valued idea; it is not amenable to reassurance. The bodily part is found to be norm al, or if abnormal is only trivially so compared with the degree of distress. It is an unusual condition which has only relatively recently come promi- nently to clinica l attention. It rarely presents directly, but such individuals may present requesting plast ic surgery or mutilating surgical procedures, and hence come to psychiatric attention. Ther e are many similarities to OCD in terms of clinical features and treatment response. Clinic al features There is preoccupation with the idea that some speci- \201 ed aspect of their appearance is grossly abnormal, markedly unattractive, or diseased. Any part of the body m ay be affected, most usually the face, head, and secondary sexual characteristics. Patients believe that the sup- posed de \201 cit is noticeable to others and attempt to hide or mi nimize it. These beliefs may develop delusional intensity. There is associated func- tional impairment, agoraphobia, and risk of suicide. Comorbid behaviors such as skin picking, rub bing, topical applications may cause worse sec- ondary problems. Clinically signi \201 can t disorder causes severe functional impairment, restriction of relationships and employment opportunities, and the risk of iatrogenic morbidity by unwarranted surgical procedures. Et iology Begins in late childhood or early adolescence, overlap with normal worries at this a ge. Epidemiology Equal sex incidence. Less than 1% prevalence but mark- edly over-represent ed in some groups (e.g. plastic surgery [10%] and der- matology). 10% incidence in \201 r st-degree family members. Comorbidity 60% risk of major depression. Differential diagnosis There is a signi \201 cant overlap in terms of symp- tom pro \201 le with social phobia, hypochondriasis, OCD, somatic delusions in schizophrenia, and anorexia nervosa. Where the c oncerns are persist- ently delusional, ICD-10 reclassi \201 es as delusional disorder, whi le DSM-IV allows diagnosis of a delusional form. Treatment \200 Operative indicated, even successful surgery risks being followed by a new preoccupation or a focus on surgical scarring. Pharmacological \202 uoxetine 20mg increa sing to 60mg. If ineffective try clomipramine up to 250mg. If delusional features, add anti psychotic. Psychological prevention, challenging cognitive errors, and behavioral tasks. Plastic surgery to the affected part is generally not Evidence for clinical effectiveness of SSRI, try Evidence for CBT, treatment focused on response Prognosis Chronic course with \202 uctuating symptom severity. Partial rather than full r emission. 19_Semple_Chap19.indd 810 12/7/2012 4:30:29 PM This page intentionally left blank CHAPTER 19 Liaison psychiatry 812 Chronic fatigue syndrome Chronic fatigue syndrome (CFS) is a clinical syndrome whose centra l fea- ture is severe fatigue, unrelated to exertion or triggered by only minimal activity, and unrelieved by rest. The fatigue is experienced as a subjective feeling of lethargy, la ck of energy, exhaustion, and a feeling of \200\230increased effort to do anything \200 \231. Patients also often complain of aching muscles, sleep disturbance, aching joints, hea daches, and dif \201 culties with concentration. They may date the onset of symptoms very precisely to an episode of viral infection with sore throat, fever, and tender lymph nodes. The syn- drome is also referred to as myalgic encephalomyelitis (ME), post-viral fatigue s yndrome, and previously as neurasthenia. The term CFS is cur- rently preferred as it does n ot imply knowledge of underlying pathology or etiology. It should be understood that CFS is not a disorder in the conventionally accepted sense, bu t a characteristic clinical syndrome. It shows diagnostic overlap with major depression, so matization disorder, and hypochondriasis but cannot be subsumed into these diagnoses becaus e of substantial areas of lack of \201 t. Any operational diagnostic criteria for CFS wil l be conten- tious and will include people with chronic organic illnesses. Patients with th is syndrome will often have passionately held beliefs about the cause of their symptoms and the appropriate management. A practical and prag- matic approach is advised from treating clinicians. Etiology Currently the etiology of CFS is unknown, with immuno- logical, geneti c, viral, neuroendocrine, and psychological causes suggested. While a minority of cases hav e a con \201 rmed onset with viral illness, ongoing viral replication or chronic infection is not the cause. The condition is likely to be heterogeneous, without a single or simple etiology. At the moment it may be best regarded as a spectrum of illness that is triggered by an acute reaction to stress or minor illness in a vulnerable individual with a persistin g clinical syndrome caused by deconditioning and other secondary phenomena. Vulnerable indi viduals are those with abnormal symptom attribution, increased awareness of normal bodily p rocesses, cognitive errors, and perfectionist personality types. Epidemiology Population pr evalence of 0.2 \200\2230.4% with women affected at four times the rate of men. Most common in people in their 40s and 50s. Occasionally occurs in children, particularly during adole scence. Diagnosis CFS should be considered where there is complaint of fatigue which: (1) i s persistent and/or recurrent; (2) is unexplained by organic conditions or other psychiatri c diagnoses; (3) results in substantial reduc- tion in previous activity level; and (4) is characterized by post-exertion malaise and slow recovery after effort, AND one or more of t he following symptoms: \200 sleep disturbance (e.g. insomnia, hypersomnia, unrefreshing sleep, disturbed sleep \200\223 wake cycle) muscles and/or joint pain without evidence of in \202 ammation headache painfu l lymph nodes \200 \200 19_Semple_Chap19.indd 812 12/7/2012 4:30:29 PM CHRONIC FATIGUE SYNDROME 813 \200 sore throat minor cognitive dysfunction (e.g. impaired concentration, impairment of STM, wo rd- \201 nding dif \201 culty) worsening of symptoms following mental or physical exertio n recurrent \202 u-like symptoms dizziness, nausea and palpitations. \200 \200 Comorbidity Many patients with CFS will meet the criteria for another psychiatric diagnosis , most commonly major depression. Many patients resist a \200\230psychiatric \200\231 diag nosis and attribute any mood disturbance to the restriction on activities caused by their i llness. Nonetheless, treat- ment of comorbid depressive or anxiety symptoms can produce cli nical improvement. Investigation \201 ndings Non-speci \201 c subjective cognitive impai rment similar to that found in depression. Normal muscle function with poor performance on tolerance testing related to deconditioning. No charac- teristic blood abnormalities or imm une system abnormalities. There are no de \201 nite and replicable abnormal \201 ndings. Do minimum indicated tests. Assessment Establish the diagnosis and identify comorbid psych iatric disorders. Avoid confrontation with the patient and attempt to agree a common unders tanding of the disorder. Acknowledge the severity of the symptoms and the consequent disabi lity. Aim to take the focus of the interview towards potentially bene \201 cial interventi ons and away from unwarranted investigations. Management There is no speci \201 c pharmacological treatment. The best evidence base exis ts for graded exercise therapy and cognitive behavior therapy. \200 Graded exercise therapy (GET) Establish via diary record the patient \200\231s daily activi ty level, establish with them their maximal tolerable level even on their worst day, and en courage them to perform this level of activity every day, no more and no less, with gradual negotiated increase over time. The aim is to break the cycle of inactivity, brief excess a ctivity, and consequent exhaustion. Cognitive behavioral therapy (CBT) Psychotropic medicat ion even where no clear-cut evidence of affective symptoms. Try SSRI \201 rst (e.g. parox etine 20mg) as this patient group is intolerant of side-effects. Symptomatic medication Pat ients may experience greater intolerance and more severe side-effects from drug treatment. Where appropriate, drugs used for symptom control should be initiated at a lower dose than in usual clinical practice, and should be increased gradually. \200 (see b p. 850). Consider antidepressant treatment trial Prognosis Outcome is dif \201 cult to predict but the severely affected cases and those wi th very chronic symptoms appear to do worse. Many patients with mild to moderate symptoms d o show some degree of improvement over time. A proportion of cases show a \202 uctuating course with periods of relative remission followed by relapse. Of the severe cases, a propo rtion will remain signi \201 cantly disabled. 19_Semple_Chap19.indd 813 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 814 Factitious disorder (Munchausen \200\231s syndrome) In factitious disorder, patients intent ionally falsify their symptoms and past history and fabricate signs of physical or mental d isorder with the primary aim of obtaining medical attention and treatment. The diagnostic f eatures are the intentional and conscious production of signs, falsi \201 cation, or exag- geration of the history and the lack of gain beyond medical attention and treatment. Three distinct subgroups are seen. \200 Wandering to job, place to place, producing dramatic and fantastic stories. There may be ag gressive personality or dissocial PD and comorbid alcohol or drug problems. Non-wandering d ramatic presentations. Often in paramedical professions; overlap with chronic somatization disorder. Association with borderline PD. By proxy staff who simulate or prolong illness in their dependants \200\224here the clinical focus must be on the prevention of further harm to the dependant. : mostly males who move from hospital to hospital, job : mostly females; more stable lifestyles and less : mostly female. Mothers, carers, or paramedical and nursing The behaviors can mimic any psychical and psychiatric illness. Behaviors include: self-indu ced infections, simulated illnesses, interference with exist- ing lesions, self-medication, altering records, reporting false physical or psychiatric symptomatology. Early diagnosis reduces iatrogenic morbidity and is facilitated by: awareness of the possibility; a neutral interviewing style using open rather than closed questions; alertness to insistencies and abnormalities in presentation; use of other available information sources; and careful medi cal record keeping. Differential diagnosis Any genuine medical or psychiatric disorder. Som atization disorder (no conscious production of symptoms and no fabrication of history), mal ingering (secondary gain for the patient, e.g. compensation, avoiding army service), substa nce misuse (also gain, i.e. the prescription of the drug), hypochondriasis, psychotic and d epressive illness (associated features of the primary mental illness). Etiology Unknown, th ere may be a background of childhood sexual abuse or childhood emotional neglect. Probably more common in men and those with a nursing or paramedical background. Association with per sonality disorder. Production of psychiatric symptoms associated with borderline PD, CSA, o r emotional abuse. Management There are no validated treatments. Patients are often reluctant to con- sider ps ychiatric assessment and may leave once their story is questioned. Management in these case s is directed towards reducing iatrogenic harm caused by inappropriate treatments and medic ations. \200 Direct challenge the patient is informed that staff is aware of the intent to feign illness Easier if there is direct evidence of feigned illness; 19_Semple_Chap19.indd 814 12/7/2012 4:30:29 PM FACTITIOUS DISORDER (MUNCHAUSEN \200\231S SYNDROME) 815 and the evidence is produced. This should be in a non-punitive manner with offer of ongoing support. Indirect challenge \200\230way out \200\231, while preventing further inappropri ate investigation and intervention. One example is the \200\230double bind \200\231 \200 \230if this doesn \200\231t work then the illness is factitious \200\231. Systemic change o f change in the individual and the focus is on changing the approach of the health care sys tem to assessing them in order to minimize harm. These strategies can include dissemination of the patient \200\231s usual presentation and distinguishing marks to regional hospitals , \200\230blacklisting \200\231, \200\230Munchausen \200\231s registers \200\231, etc. As these strategies potentially break con \201 dentiality and can decrease the risk of detec ting genuine illness, they should be drawn up in a multidisciplinary fashion involving seni or staff. Here the aim is to allow the patient a face-saving Here the understanding is that there is no possibility 19_Semple_Chap19.indd 815 12/7/2012 4:30:29 PM CHAPTER 19 Liaison psychiatry 816 Assessment prior to organ transplantation For patients with end-stage organ disease (e.g. k idney, liver, heart, lung, bowel, or pancreas), a transplant offers the prospect of signi \201 cant improve- ment in their mortality and quality of life. Unfortunately, the supply o f donor organs is less than the number of potential recipients. Because of this, patients r equiring transplantation will suffer declining health while on the waiting list, and a prop ortion of listed patients will die while awaiting transplant. This places a responsibility on the assessing team to consider carefully each potential candidate for listing for transp lantation in order to ensure the best use of the donor organs. Psychiatric assessment of pa tients prior to listing for organ transplantation may be requested in the following situati ons: \200 In some patients being considered for liver transplantation: \200 \200 Patients with hi story of mental illness Patients with previous or current drug misuse Patients with history of non-compliance Living related donors Fulminant liver failure following overdose (usually paracetamol) Liver disease secondary to alcoholic liver disease (ALD) \200 \200 \200 The involvement of the psychiatrist in the assessment prior to listing for transplantation should in no sense be a moral judgment as to the patient \200\231s suitability. The issues are whether there are psychiatric factors which would jeopardize the survival of the donor organ. The psychiatric opinion may have the most profound implications for the patient and so assessment should be as thorough as time allows. In addition to taking psy- chiatric his tory and MSE, family members, GP, and hospital case records should be consulted. Fulminant liver failure This will often follow on from a late presenting paracetamol overdose. At the point patients are seen it is often unclear whether they are going to recover or to deteri orate to the point of requir- ing transplant. They should be seen as soon as possible after presentation as encephalopathy may develop as their condition worsens. The issue is whethe r there is: ongoing intent to die or refusal of transplant (which would normally preclude t ransplantation); or whether there is a history of repeated overdoses in the past, signi \201 cant psychiatric disorder, or ongoing drug or alcohol misuse (which would be relative contraindications). Liver disease secondary to ALD Suitably selected patients trans- plante d for ALD have similar outcomes in terms of survival and quality of life to patients transp lanted for other indications. Units will have individual policies regarding these patients which should be consulted if available. The issue is whether the patient, who has already d amaged one liver, will damage a second. There is a wider issue of maintaining the public co n \201 - dence in the appropriate use of donated organs. Consider: \200 How long have they been abstinent (is there independent veri \201 cation of this)? Do they accept alcohol as the cause of liver failure? 19_Semple_Chap19.indd 816 12/7/2012 4:30:30 PM ASSESSMENT PRIOR TO ORGAN TRANSPLANTATION 817 \200 \200 Do they undertake to remain abstinent post-transplant? Do they have a history of dependence or harmful use? What is their history of involvement in alcohol treatment services and, in the past, how have they responded to relapse? When were they told that their drinking was causing liver damage, and what was their response? Given these \201 ndings and your routine psychiatric assessment, the trans- plant team wi ll seek your opinion as to: \200 The patient \200\231s psychiatric diagnosis \200 Their risk of relapse \200 Their risk of re-establishing harmful/dependent drinking \200 The potential for successful intervention should this occur History of mental illness/drug misuse Generally speaking, a diagnosis of mental disorder (o ther than progressive dementia) will not preclude transplant. The important issues are whet her the mental dis- order will affect compliance or longer-term mortality in its own right. Close liaison with the patient \200\231s normal psychiatrist is clearly crucial here. Ongo ing substance dependence is generally a contraindication to trans- plantation and should be addressed before listing. History of non-compliance with treatment Non-compliance with tre atment may be the reason for a patient \200\231s need for transplant, or place the patient at risk for future morbidity or mortality and the loss of a donated organ if not recognized early in assessment. Past medical records and discussions with past treatment teams will p rovide informa- tion regarding this area of risk for a given patient or family. In addition , pre-transplant evaluation by multiple team members, including behav- ioural health, shoul d identify psychosocial factors that place a patient or family at risk for non-adherence, a nd provide the team an opportunity to be proactive to increase the likelihood of future adh erence and transplant success. Living related donors This type of transplant uses organs or tissues from a matched and usually biologically related donor. Examples include bone marro w, single kidney or portion of liver. In this case, the donor is an additional focus of eva luation, with the goal of establishing that there is valid consent and the absence of coerc ion. 19_Semple_Chap19.indd 817 12/7/2012 4:30:30 PM This page intentionally left blank 819 Chapter 20 Psychotherapy Introduction 820 Assessment for psychotherapy 822 A brief history of Sigmund Freud 824 Othe r pioneers of psychoanalysis 826 Basic psychoanalytical theory 828 Defense mechanisms 830 T heory of psychosexual development 832 Object relations theory 834 Psychoanalysis 1 836 Psyc hoanalysis 2 838 Psychodynamic psychotherapy 840 Group psychotherapy 842 Basic learning the ory 844 Behavior therapy 848 Cognitive behavioral therapy 1 850 Cognitive behavioral therap y 2 852 Interpersonal psychotherapy 854 Dialectical behavior therapy 856 Cognitive analytic therapy 858 Solution-focused therapy 860 Counseling methods 862 20_Semple_Chap20.indd 819 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 820 Introduction The psychotherapies are a collection of treatments for mental disorder which e mploy language and communication, and the relationship with a skilled therapist, as their m eans of producing change. Psychotherapeutic methods are used both to conceptualize abnormal mental states (to understand why symptoms have developed in this patient at this particula r time), and to treat symptoms and disorders. Generally the aim of therapy is to enable patients to improve their relationships with them selves and others as well as to manage and treat symptoms. The core components of psychothe rapy, regardless of the underlying theoretical basis, are an empathetic and non-judgemental stance towards the patient, an awareness of the importance of the setting in which therapy takes place and the use of the therapeutic relation- ship between the therapist and patien t as both a diagnostic and thera- peutic agent. Types of psychotherapy Supportive psychotherapy This form of psychotherapy aims to offer pr actical and emotional sup- port, opportunity for ventilation of emotions, and guided, probl em-solving discussion. There is no explicit attempt to alter underlying cognitions or to di smantle adaptive defense mechanisms. Supportive psychotherapy is sometimes preferred where fundamental behavioral change is not aimed for, or where patient factors (e.g. learning dif \201 culty, psychotic illness) pre- clude exploratory therapies. Examples include counsel ing and general psychiatric follow-up. Psychodynamic psychotherapy This form of therapy aims to produce changes in individuals \200\231 thinking and behavior by exploring childhood experience, the unconscious mind incl uding transference (see b p. 828), and the quality and nature of relationships both in the past, the present, and in the here-and-now with the therapist. The latter receives particul arly close analysis as it allows for understandings to come directly rather than via third party report by the patient. Ideally patients should be highly motivated, able to tolerate frus- tration and anxiety, have good impulse control, be able to form meaningful relationsh ips and be capable of insight and abstract thought. These traits however could be regarded as being the markers of health rather than the sign that somebody needs treatment and as su ch a balance needs to be struck between a triad of factors \200\224does the patient want th erapy, do they need therapy, and can they use therapy? Cognitive and/or behavioral therapies These are based on learning and cognitive theories wi th the rationale that a patient \200\231s thoughts, feelings, and actions are interdependen t on one another. Attention in these therapies is directed towards the patient \200\231s cu r- rent thoughts and behaviors which are closely examined and challenged, with a view to mo di \201 cation to improve symptoms. Unconscious pro cesses, childhood experience, and the speci \201 c nature of the therapist \200\223patient rela- tionship receive less attention . Cognitive and behavioral therapy sessions 20_Semple_Chap20.indd 820 12/7/2012 4:32:53 PM INTRODUCTION 821 are generally more structured than in other psychotherapies and often take place over a rel atively brief and predetermined period of time. These therapies are useful in a wide range of disorders including depression, anxiety disorders (including OCD), eating disorders and, more recently they have been applied to psychotic disorders. Psychotherapeutic training As a psychiatric trainee, you are required to gain competency in \201 ve areas of psychotherapy \200\224supportive psychotherapy, psychodynamic psycho- t herapy, brief psychotherapies, cognitive behavioral therapy, and com- bined psychopharmacol ogy/psychotherapy. Training generally consists of formal teaching, experience working with a range of patients, and regular supervision with experienced therapists. It is only throug h the process of conducting therapy under supervision that you will really understand psy- chotherapeutic techniques. These notes on general concepts and speci \201 c psychotherapie s aim to familiarize you with theories, guide your referrals, and assist you in explaining the process to patients. Recommended further reading Dewan M, Steenbarger B, and Greenburg R (2004)The art and scien ce of brief psychotherapies. Arlington: American Psychiatric Publishing, Inc. Gabbard GO (2000) Psychodynamic psychiatry in clinical practice, 3rd edn. Washington, DC: American Psychiatric Press, Inc. Malan D (1995) Individual psychotherapy and the science of psychodynamics. London: Hodder A rnold Publications. Padesky CA and Greenberger D (1995) Mind over mood: change how you feel by changing the way you think: New York: Guilford Publications. Winston A, Rosenthal R, and Pinsker H (2004) Introduction to supportive psychotherapy. Arli ngton: American Psychiatric Publishing, Inc. 20_Semple_Chap20.indd 821 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 822 Assessment for psychotherapy Indications and contraindications \200 Psychotherapeutic methods can be useful in the treatment of many psychiatric illnesses, inc luding mild to moderate depressive illness, neurotic illnesses, eating disorders, and perso nality disorders. Speci \201 c therapies also have a place in the management of patients w ith learning disabilities, those with psychosexual problems, substance misuse disorders, an d chronic psychotic symptoms. contraindicated in: They are generally acute psychosis (due t o increasing expressed emotion and the \200 inherent neuropsychological de \201 cits ass ociated with this mental state); severe depressive illness dementia/delirium \201 rst-lin e); some individuals where there is \200 (because of psychomotor retardation); (where treatment of organic pathology is acute suicide risk. Goals of assessment The assessment of a patient for psychotherapy has three major goals: \200 \200 want from therapy)? What does the patient expect (or Obtaining a careful history/narrative of the problem from the patient (do they need therapy?) Establishing whether the patient can form a therapeutic relationship and make use of the type of therapy being potentially offered. Different therapies will have a varying focus in the initial assessment, e.g. psychodynamic assessments will often focus more on relational aspects of the patient \200\231s life wher eas cognitive behavioral therapists may concentrate more on the (A)ntecedents, (B)ehaviours /(B)eliefs, and (C)onsequences of the patient \200\231s behaviors or beliefs. Psychological factors in assessment for psychotherapy \200\230Psychological-mindedness \200\231 Refers to the capacity for insight and to unders tand problems in psycho- logical terms: \200\230can the patient think about their thoughts ? \200\231. If this is lacking, a supportive method may be preferred over a cognitive or ex ploratory method. Motivation for insight and change Many patients (and trainees!) do not want to \200\230get better \200\231 or change. Often we are more comfortable playing by the rules of the game we know, even if this means we \201 nd ourselves caught in dif \201 cult situations, rat her than learning a new game. An important part of assessment is to establish whether the p otential patient is willing to take responsibility for their situ- ation and use therapy as a means of changing it. Adequate ego strength and reality testing Important when considering exploratory psychother apies, especially those based on exploring transference dynamics. Includes the ability to s ustain 20_Semple_Chap20.indd 822 12/7/2012 4:32:53 PM ASSESSMENT FOR PSYCHOTHERAPY 823 feelings and fantasies without impulsively acting upon them, being over- whelmed by anxiety , losing the capacity to continue the dialog, or treat- ing \200\230as if \200\231 situati ons as though they \200\230actually are \200\231 real. Ability to form and sustain relationships Where there is inability to enter into trusting r elationships (e.g. in para- noid personality disorder) or where there is inability to maint ain relation- ship boundaries (e.g. in borderline personality disorder), this may preclude exploratory methods. Able to tolerate change and frustration As with any potentially powerful treatment, psychot herapy has the poten- tial to exacerbate symptoms, particularly when maladaptive coping mec ha- nisms are examined and changed. Selection of psychotherapeutic method Local availability In practice, often the main determinant of therapy choice is local avail abil- ity and the practical availability determined by the length of the waiting list. The waiting times associated with most forms of therapy should encour- age all practitioners to exercise care in patient referral. Practitioner experience and view of modality Where the treating psychiatrist also provides the psychotherapy, his or her area of expertise may determine choice of psychotherapeutic m ethod. Illness factors Varying illnesses and states of mind have been shown, within the evidence b ase, to respond differentially to different treatments. Patient choice Patients may express a preference for a particular therapeutic model because of previous positive experience or having read or been told about the approach. A method w hich \200\230makes sense \200\231 to the patient given their understanding of their sympto ms is often preferred. 20_Semple_Chap20.indd 823 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 824 A brief history of Sigmund Freud Freud remains far and away the world \200\231s best-known psychiatrist and his image, of a scholarly, bearded man sitting behind a distressed patient lying on a couch, is many lay-people \200\231s archetype for our profession. He made a hug e contribution to our understanding of the mind, but many of his ideas are now so much a pa rt of our general view of the world that it is easy to overlook the breakthroughs they orig inally were. He was born in 1856 in Moravia (now part of the Czech Republic, but then part of the Austro -Hungarian Empire). He moved to Vienna when he was a child and lived there until his last y ear. On entering medical training he was in \202 uenced by scienti \201 c empiricism \200 \224the belief that through careful observation the un-understandable could be understood. On quali \201 cation he began laboratory work on the physiology of the nervous system unde r Br cke, later entering clinical medical practice after his marriage in 1882. He chose ne urology as his specialty and received a grant to study at the Salp tri re in Paris, where he was exposed to the ideas of Charcot, who interested Freud in the study of hysteria and the use of hypnosis. In Paris with Charcot, and later in Nancy with Li bault, he studied t he behav- iour of hysterical patients under hypnosis and developed his ideas of the unconsc ious mind and its role in normal and disordered behavior. Returning to Vienna, Freud began collaboration with Josef Breuer on the study of hysteria. The subsequent development of psychoanalysis was prompted by the case of Anna O., treated b y Breuer between 1880 and 1882. This patient, a 21-yr-old woman (real name Bertha Pappenhei m), presented with a range of hysterical symptoms including paralysis, visual loss, cough, and abrupt personality change. These symptoms had devel- oped while her father was terminal ly ill. Breuer observed that her symp- toms resolved during hypnotic trances. Breuer also n oted that not only did the symptoms recur after the sessions ended, but that after he termi - nated the treatment relationship she suffered a full-blown relapse. Breuer wrote up the c ase after discussing it with his younger colleague. Later they published Studies in hysteri a, detailing their ideas on the etiology and treatment of hysterical symptoms. This book po stulated that trauma is unacceptable to the patient and hence repressed from conscious memo ry. This repression produces an increase in \200\230nervous excitation \200\231 \200\224wh ich is expressed eventually as hysteria \200\224with a conscious remnant, often in a disgui sed form, which can be accessed and resolved during hypnosis. Freud explored these ideas during his clinical practice in the 1890s, using a variety of me thods to uncover the repressed memories. Later he developed the technique of free associati on, where the patient is encour- aged to say whatever comes to mind. Experience in the 1890 s led Freud to develop the ideas of repression of unacceptable memories and their expressio n as hysterical symptoms. The initial memory was generally of a sexual nature. At \201 rs t Freud thought this was a real, remembered assault, but later realized that in the majorit y of cases the patients were describing a sexualized fantasy towards parental \201 gures. Freud described these ideas in his most famous book, The interpretation of dreams, publish ed in 1900. It described the basis of his psychoanalytic technique including analysis of th e content of dreams, descriptions of defense mechanisms, and his 20_Semple_Chap20.indd 824 12/7/2012 4:32:53 PM A BRIEF HISTORY OF SIGMUND FREUD 825