Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Patients (especially inpatients) are encouraged to become self-reliant by doing such simple things as making their own beds, doing their own shopping, and preparing their own meals. This process is called self-reliance training. Role play- ing is a particularly powerful and useful technique to elicit automatic thoughts and to learn new behaviors. Diversion techniques are useful in helping patients get through difficult times and include physical activity, social contact, work, play, and visual imagery. Imagery or thought stoppage can treat impulsive or obsessive behavior. For instance, patients imagine a stop sign with a police officer nearby or another image that evokes inhibition at the same time that they recognize an impulse or obsession that is alien to the ego. Similarly, obesity can be treated by having patients visu- alize themselves as thin, athletic, trim, and well muscled, and then training them to evoke this image whenever they have an urge to eat. Hypnosis or autogenic training can enhance such imagery. In a technique called guided imagery, therapists encourage patients to have fantasies that can be interpreted as wish fulfillments or attempts to master disturbing affects or impulses. Efficacy Cognitive therapy can be used alone in the treatment of mild to moderate depressive disorders or in conjunction with anti- depressant medication for major depressive disorder. Studies have clearly shown that cognitive therapy is effective and in some cases is superior or equal to medication alone. It is one of the most useful psychotherapeutic interventions currently available for depressive disorders, and it shows promise in the treatment of other disorders. Cognitive therapy has also been studied as a way of increas- ing compliance with lithium (Eskalith) prescription by patients with bipolar I disorder and as an adjunct in treating withdrawal from heroin. Table 28.7-4 outlines Beck’s criteria for determin- ing when cognitive therapy is indicated. R eferences Beck AT, Freeman A, Davis DD. Cognitive Therapy of Personality Disorders. 2 nd ed. NewYork: Guilford; 2003. Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: Evaluating current evidence and informing future research. Psychol Conscious Theory Res Pract. 2013;1(Suppl):97–107 Dobson KS. The science of CBT: Toward a metacognitive model of change? Behav Ther. 2013;44(2):224–227. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individu- als with chronic pain: Efficacy, innovations, and directions for research. Am Psychol . 2014;69(2):153. Hollon SD. Does cognitive therapy have an enduring effect? Cognit Ther Res. 2003;27:71–75. Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, Parr-Davis G, Pak S. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Arch Gen Psychiatry. 2003;60:145–152. Leahy RL, ed. Contemporary Cognitive Therapy: Theory, Research, and Practice. NewYork: Guilford; 2004. Mulder R, Chanen AM. Effectiveness of cognitive analytic therapy for personality disorders. Br J Psychiatry. 2013;202(2):89–90. Newman CF, Beck AT. Cognitive therapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Vol. 2. Phila- delphia: Lippincott Williams & Wilkins; 2009:2857. Rector NA, Seeman MV, Segal ZV. Cognitive therapy for schizophrenia: A pre- liminary randomized controlled trial. Schiz Res. 2003;63:1–11. Reinecke MA, Clark DA. Cognitive Therapy Across the Lifespan: Evidence and Practice. Cambridge, UK: Cambridge University Press; 2003. Sturmey P. On some recent claims for the efficacy of cognitive therapy for people with intellectual disabilities. J Appl Res Intellect Disabil. 2006; 19:109–117.

and diversion techniques. One of the first things done in therapy is to schedule activities on an hourly basis. Patients keep records of the activities and review them with the therapist. In addition to scheduling activities, patients are asked to rate the amount of mastery and pleasure their activities bring them. Patients are often surprised to learn that they have much more mastery of activities and enjoy them more than they had thought. To simplify the situation and allow miniaccomplishments, therapists often break tasks into subtasks, as in graded task assignments, to show patients that they can succeed. In cogni- tive rehearsal, patients imagine and rehearse the various steps in meeting and mastering a challenge. Criteria that justify the administration of cognitive therapy alone: Failure to respond to adequate trials of two antidepressants Partial response to adequate dosages of antidepressants Failure to respond or only a partial response to other psychotherapies Diagnosis of dysthymic disorder Variable mood reactive to environmental events Variable mood that correlates with negative cognitions Mild somatoform disorders (sleep, appetite, weight, libidinal) Adequate reality testing (i.e., no hallucinations or delusions), span of concentration, and memory function Inability to tolerate medication effects or evidence that excessive risk is associated with pharmacotherapy Features that suggest cognitive therapy alone is not indicated: Evidence of coexisting schizophrenia, dementia, substance- related disorders, mental retardation Patient has medical illness or is taking medication that is likely to cause depression Obvious memory impairment or poor reality testing (hallucinations, delusions) History of manic episode (bipolar I disorder) History of family member who responded to antidepressant History of family member with bipolar I disorder Absence of precipitating or exacerbating environmental stresses Little evidence of cognitive distortions Presence of severe somatoform disorders (e.g., pain disorder) Indications for combined therapies (medication plus cognitive therapy): Partial or no response to trial of cognitive therapy alone Partial but incomplete response to adequate pharmacotherapy alone Poor compliance with medication regimen Historical evidence of chronic maladaptive functioning with depressive syndrome on intermittent basis Presence of severe somatoform disorders and marked cognitive distortions (e.g., hopelessness) Impaired memory and concentration and marked psychomotor difficulty Table 28.7-4 Indications for Cognitive Therapy

Major depressive disorder with suicidal danger History of first-degree relative who responded to antidepressants History of manic episode in relative or patient

(Adapted from Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression . New York: Guilford; 1979:42.)