HD 3700 1st Edition Lecture 25Outline of Last LectureI. Beck’s Great Discovery: Automatic ThoughtsII. A “Common Sense” Approach To Feelings And ConflictsIII. The CBT RevolutionIV. Case Study: NickV. CBT and SCZOutline of Current LectureI. How to study for the finalII. Treating SCZIII. Psychodynamic therapyIV. Psychodynamic formulation with inpatient BPD—Liza V. Ophelia’s psychotic griefCurrent LectureI. 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 questiono 1. Diagnosis: Given Jim’s presenting symptoms, suggest and support a psychiatric diagnosis Major depressive episodeo 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 needso 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 reuptakeo 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 choiceo Anxiety disorderso Biology of anxietyo Anxiolytics—how they work on nervous systemo Personality disorders—read the chapter in readero Psychotherapy: different schools including the case studies two red chairs and all by myselfo HamletII. 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 therapistIII. Psychodynamic Therapy- Assumes some of the principles of psychoanalysis: o a “dynamic unconscious,”o defenses against painful or threateningideas or feelingso use of transferenceo deepening the awareness of the patient.- But…o No coucho No “analytic silence”o No “blank screen of the analyst”o Attention to cognitive distortions, real-life problemsIV. Psychodynamic formulation with inpatient BPD—Liza - Liza Bo 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 himo Able to understand her triggers- Initial presentation of Lizao 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 teamproduced the following problem list:o 1. Suicidality: consisting of ideation, impulsive gestures, and planned attemptso 2. Depression : sleep disturbance, hopelessness, guilt, suicidal ideation, poor concentration, anhedonia, fatigue, low self-esteem, irritabilityo 3. Self-Mutilating Behaviors : includes scratching and cutting of wrists andlegso 4. PTSD symptoms : flashbacks, nightmares, panic attacks associated with memories ofthe sexual abuseo 5. Separation issues: separation and perceived abandonments appear to stimulate depression, PTSD symptoms, suicidality and self-mutilating behaviorso 6. Poor LesiureActivities : could list virtually no interests or activities aside from talking with friendso 7. Mother/Daughter Issues : turbulent dependence upon mom; rage at separations, remarriage, and for the initial abuse by biological fathero 8. Enemia:: appropriate medical treatment will be providedo 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 knowingmore 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