HD 3700 1st Edition Lecture 25 Outline of Last Lecture I Beck s Great Discovery Automatic Thoughts II A Common Sense Approach To Feelings And Conflicts III The CBT Revolution IV Case Study Nick V CBT and SCZ Outline of Current Lecture I How to study for the final II Treating SCZ III Psychodynamic therapy IV Psychodynamic formulation with inpatient BPD Liza V Ophelia s psychotic grief Current Lecture I How to study for the final Wednesday May 13th 2 4 00 PM A cumulative question Given a description of a patient you ll be asked to give a psychoanalytic object relations or cognitive or neurobiological explanation a diagnosis a recommendation for medication if any and a brief account of the patient undergoing psychotherapy worth 60 points 40 multiple choice questions covering the material from Anxiety through Psychotherapy 40 points Four parts to the question o 1 Diagnosis Given Jim s presenting symptoms suggest and support a psychiatric diagnosis Major depressive episode o 2 Psychoanalytic Psychodynamic formulation Next consider Jim s developmental history How does your understanding of Freud s view of the mind of the psychosexual stages shed light on Jim s recurring symptoms How about the stages of self development from the object relations model Psychoanalytic formulation look at slide on object relations and development of self major event from childhood cancer death of mother when he was 6 end of the oedipal relationship never resolved sense of self he could remember her trigger of his depression was breakup with girlfriend depressive episodes after breakups loss of mother a trauma he hasn t recovered from has been seeking those basic attachment needs in relationships with women almost as if he can t live without his mom Object relations loss of mother left him with unresolved dependency needs o 3 Medication Would you recommend a trial of psychotropic medication If not why If so why and what class of medication would you recommend Briefly describe how that class of medication works on the brain Medication CBT teach him how to deal with breakups because triggered by abandonment have contract with him that he wouldn t attempt suicide SSRIs because maybe depression so overwhelming can t make use of therapy SSRIs increase levels of serotonin in synapse by blocking reuptake o 4 Psychotherapy Recommend a course of psychotherapy choosing among the various kinds you learned about this semester First list the main features of the therapy then describe how it would likely unfold if you were to conduct the therapy with Jim Psychotherapy CBT say going to give depression inventory every week assess him have him right a journal to identify issues or psychoanalysis to look at past and get him to solve issues from his past What to study for multiple choice o Anxiety disorders o Biology of anxiety o Anxiolytics how they work on nervous system o Personality disorders read the chapter in reader o Psychotherapy different schools including the case studies two red chairs and all by myself o Hamlet II Treating SCZ review from last lecture Yale Psychiatric Institute step one SCZ episode step two inpatient hospitalization one year step three Day hospital two years All state mental hospitals closed down Now if you have SCZ break might be in hospital for week while they medicate stabilize you and maybe you go between treatment partial hospitalization family therapy sessions referred to outpatient program or therapist III Psychodynamic Therapy Assumes some of the principles of psychoanalysis o a dynamic unconscious o defenses against painful or threateningideas or feelings o use of transference o deepening the awareness of the patient But o No couch o No analytic silence o No blank screen of the analyst o Attention to cognitive distortions real life problems IV Psychodynamic formulation with inpatient BPD Liza Liza B o Had been hospitalized 5 times over the past year claimed that she began having terrible flashbacks of sexual abuse at the hands of her father parents split up when she was 6 got back together one day saw her father with a child that was from a different relationship fear that he would abuse the boy started her flashbacks wanted to kill him o Able to understand her triggers Initial presentation of Liza o Upon admission Liza met criteria for major depressive episode exhibited psychomotor retardation and agitation and stated continually that she did not feel safe During the first days on the unit she made an attempt to scratch herself and was placed on one to one observation o Her formulation conference held by her multi disciplinary treatment team produced the following problem list o 1 Suicidality consisting of ideation impulsive gestures and planned attempts o 2 Depression sleep disturbance hopelessness guilt suicidal ideation poor concentration anhedonia fatigue low self esteem irritability o 3 Self Mutilating Behaviors includes scratching and cutting of wrists and legs o 4 PTSD symptoms flashbacks nightmares panic attacks associated with memories ofthe sexual abuse o 5 Separation issues separation and perceived abandonments appear to stimulate depression PTSD symptoms suicidality and self mutilating behaviors o 6 Poor LesiureActivities could list virtually no interests or activities aside from talking with friends o 7 Mother Daughter Issues turbulent dependence upon mom rage at separations remarriage and for the initial abuse by biological father o 8 Enemia appropriate medical treatment will be provided o 9 Discharge Planning deferred but consider long term psychiatric placement following evaluation Clinical formulation Liza o Liza is extremely reticent even with staff that she trusts without knowing more of her history or even current feelings it is difficult to present a complete formulation Certainly the repeated sexual abuse by her father constitutes a trauma which drastically affects her perceptions of her self and others While her reality testing is most affected by flashbacks of the abuse which are often followed by periods of derealization and depersonalization her object relations are constantly distorted by projective identification The abuse which may well have been violent as well as sexual was so intolerable that the young child could not reconcile its meaning At one point it may have seemed justified because she was bad and at others she may have internalized her father s sadistic rage and directed it back toward him almost as a mirror o In this way Liza s rage at being