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[BLOG POST] Interventions For Behavioral Problems After Brain Injury – BrainLine

by Carrie Beatty, CBIS, ResCare Premier
Interventions For Behavioral Problems After Brain Injury

Introduction

Behavior change is difficult for any individual to accomplish. The process, however, can be infinitely more difficult for those who suffer from a traumatic brain injury (TBI) due to physical, cognitive, and emotional impairments associated with an injury. Successful reintegration into the community and return to activities of choice is often dependent on the individual’s ability to modify maladaptive behaviors that may result from the injury. Behavioral challenges that frequently require intervention following brain injury include aggression, disinhibition, difficulty relating to others, and a host of other behaviors.

A total reversal of behavioral problems after a brain injury may not be possible. A more realistic goal is to modify behaviors. There are several interventions available to assist with the modification of those behaviors that negatively effect goal achievement, successful community reintegration, or quality of life for individuals with TBI. The intent of this article is to describe and provide examples of current options for therapeutic intervention and examine their effectiveness for individuals with TBI.

Proactive Measures

There are a number of steps that can be taken proactively to set the stage in developing effective plans for behavior change.

Developing Trusting Relationships

It is important to build a trusting relationship with an individual who has had a brain injury. Much of what occurs during rehabilitation is based on trust that the individuals providing services understand what is important to the person receiving services. There must be trust that the recommendations providers make and activities they encourage, are designed to help the individual achieve his/her goals.

Trust is developed through honest, caring, and consistent interactions. It is important to be realistic with the individual. You cannot promise to ‘make him/her better.’ We, as family members or professionals, do not have all the answers to the individual’s problems. We may be most helpful by providing a comfortable, nonjudgmental atmosphere in which the individual can discuss his/her concerns and preferences, even if the concerns and the accompanying behaviors do not appear to be logical. The knowledge gained from such discussions is invaluable when developing behavior plans or carrying out treatment.

The importance of relationships in behavior change goes beyond relationships between professionals and a person with brain injury. Following a brain injury, an individual may feel isolated and depressed (Denmark & Gemeinhardt, 2002). Success in coping with or adapting to changes after injury, as well as in modifying maladaptive behaviors, is highly dependent upon the feedback and support an individual receives from his/her social network. A supportive network may include professionals, family, old friends, new friends, and persons who have had similar experiences.

Understanding the Behavior

Developing adaptive behavior first requires recognizing what may be contributing to the problematic behavior. Triggers, antecedents, and precipitating factors are terms describing that which precedes the behavior. Triggers to acting-out behavior may be internal or external (Caraulia & Steiger, 1997). Examples of internal causes of behavioral problems can be fatigue, hunger, lowered self-esteem, etc. External triggers may include a frustrating task, interaction with certain individuals, change in structure/ routine, increased level of stimulation, etc. In addition to understanding what may trigger maladaptive behavior, it is important to understand what occurs following the behavior that may serve to reinforce and hence maintain the behavior. For example, if a given behavior consistently results in a rewarding experience such as increased attention, the frequency of the behavior will most likely increase. Modification of antecedents and consequences to change behavior is discussed in more detail under the heading Behavior Therapy.

Recognizing and Responding to Precursors

Individuals often provide non-verbal and verbal signs prior to displaying the behavior of concern. A person’s change in behavior can represent a negative internal state. There may be signs of anxiety such as pacing and fidgeting. The face may become flushed; he/she may have difficulty maintaining eye contact or may display decreased attention to a task. An individual may also exhibit verbal signs, such as muttering to him/herself or increasing the volume of speech. Clearly, it is important to be aware of sudden, often subtle, changes in behavior (both non-verbal and verbal) in order to effectively intervene. Intervening early in the sequence of behavioral escalation is one of the most effective strategies for behavior change.

General Guidelines

In order to select the most appropriate intervention for modifying behavior during rehabilitation, the following guidelines, outlined by White, Seckinger, Doyle, and Strauss (1997), need to be considered:

  • Include the individual with TBI when developing a strategy. If a plan is developed without client input, it is not likely to be effective.
  • Prioritize the functional needs of the individual. Consider his/her strengths and weaknesses.
  • Analyze the tasks required for goal achievement. Individuals have more success if they can incorporate what they have already learned and know.
  • Consider the learning style. Individuals can learn from written information, oral information, or a combination of both. Ensure the intervention is compatible with the learning style of the individual.
  • Consider the individual’s willingness to participate in the therapy or strategy.
  • Ensure that the strategy is practical. Time and funding constraints, family concerns, and environment limitations (i.e., in-patient vs. day-patient) should be considered.

Therapeutic Interventions

Several different approaches have been used to modify behavioral problems in individuals with TBI, some with more success than others. Most of the therapeutic intervention strategies were developed originally for individuals with learning disabilities, emotional dyscontrol, and psychiatric disorders. Studies have shown that with some adjustments or combination of approaches, these intervention strategies can benefit individuals with TBI (Alderman, 2003). However, most researchers agree that additional studies should be conducted to better measure the effectiveness of therapeutic interventions that have been adapted for use with persons with TBI (Denmark & Gemeinhardt, 2002; Kinney, 2001; Manchester & Wood, 2001; Schlund & Pace, 1999).

Insight Oriented Psychotherapy

Insight oriented psychotherapy can be defined as a process to gain more awareness and insight into our thoughts, feelings, and behaviors (Pologe, 2001). Theoretically, the more awareness one has of thoughts, feelings, and behaviors, the more one is able to change them. Therefore, insight oriented psychotherapy guides an individual to gain this awareness in order to change behavioral patterns. This type of therapy requires the individual to attend to task, maintain thought process, recall what is occurring (or occurred) during therapy, use reason, and develop insight. Considering these requirements, it is understandable that individuals with TBI, who may have problems with attention, memory, thought organization, or abstract processing, may not benefit from insight oriented psychotherapy. For this reason, Wood and Worthington (2002) concluded that insight oriented psychotherapy could only be implemented with individuals who have suffered mild or moderate debilitating effects.

For individuals with traumatic brain injuries who do not have severe cognitive deficits, insight oriented psychotherapy may be very beneficial. Prigatano (1986) suggested that a goal of psychotherapy for individuals with TBI should be to increase understanding of what has happened, the injury, and its effects. It should also help the person develop strategies for acceptance of injury, achieve self-acceptance, be realistic, and adjust to role and relationship changes. Finally, the process may be used to increase social appropriateness and develop behavioral strategies. Insight oriented psychotherapy for individuals with TBI is often conducted in a group in the rehabilitation setting. The group setting adds opportunities for feedback from peers that may enhance insight. Group therapy may not be productive, however, for individuals who are unable to filter out external stimuli and selectively attend to the task at hand, for those who become overly stimulated in a group setting, or for those who easily become frustrated or aggressive (Bennett & Raymond, 1997).

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a specific form of psychotherapy that is concerned with how people’s behavior is shaped by their interpretation and perception of their experience (Alderman, 2003). It aims at assisting the individual in understanding the link between beliefs, thoughts, feelings, and behavior. That is, there is often a belief (realistic or not; adaptive or maladaptive) that underlies one’s thoughts and results in a pattern of behavior that is consistent with that belief. Needless to say, belief patterns that existed prior to the injury or those that are developed post-injury affect progress in rehabilitation.

In cognitive behavioral therapy, the individual is required to analyze maladaptive behavior in regard to any underlying beliefs that may be untrue, unrealistic, or counterproductive to meeting basic needs. The benefit of this approach is that one can alter behavior by changing beliefs or the way one thinks when it may not be possible to change the external situation (Albert Ellis Institute & Abrams, 2004). For example, a teenager may be suspended multiple times for fighting in school. She reveals to her counselor that she has the following belief: “the way to deal with hostility is to be hostile in return — an eye for an eye and a tooth for a tooth.” Her counselor suggests alternative beliefs that would alter her emotional response and help her to avoid fights in school. In this case, alternative beliefs might include, “ignoring or walking away from another person’s hostility keeps me out of trouble” or “being hostile in return doesn’t improve the situation in the long run.” The process requires that an individual take an active role in the application of techniques. Homework may be assigned so that techniques are practiced. Furthermore, the individual may be required to monitor his/her own behavioral responses (self-monitoring). This process builds awareness of behavioral patterns (including frequency, type of response, etc.), and leads to the individual taking more responsibility for altering his/her own behavior (Denmark & Gemeinhardt, 2002).

Effectiveness of cognitive behavioral therapy with individuals who have a TBI is dependent upon the individual’s level of cognitive functioning. For example, the following personal characteristics are required to participate in Rational Emotive Behavioral Therapy (REBT) which is a form of cognitive behavioral therapy: self-direction, good ability to tolerate frustration, flexibility, acceptance of uncertainty, self-acceptance, nonutopianism (accepting the fact that one will never achieve a utopian or ideal existence), and ability to take responsibility for one’s own emotional disturbances (Ellis & Dryden, 1997). Additionally, in REBT self-defeating thoughts and feelings are openly challenged. Discussion in either individual or group settings can be quite direct and demanding. Consequently, it has been suggested that a more flexible protocol of REBT be implemented for individuals with TBI. It should be more collaborative, less directive, and more flexible. In this sense, the therapist might adapt to the needs of the individual rather than the individual adapting to the REBT (Kinney, 2001). Manchester and Wood (2001) advocate that if REBT or another form of psychotherapy is used with persons with brain injury that the sessions be highly structured, repetitive, and include role play. They suggest that through procedural learning (repetition and structure), the likelihood will increase that cognitive behavioral therapy will be successful.

Behavior Therapy

The goal of behavior therapy is to manipulate the person’s environmental antecedents (that which consistently precedes a behavior) and consequences (that which follows or results from the behavior) in order to decrease the likelihood of maladaptive behaviors occurring and increase more positive, adaptive behaviors (Denmark & Gemeinhardt, 2002). Typically, individuals who are not appropriate for insight oriented psychotherapy or cognitive behavioral therapy are able to benefit from behavior therapy. Behavior therapy is currently accepted as an effective intervention for modifying behavior following TBI. For example, there is evidence suggesting that if behavior therapy intervention is properly implemented to meet the needs of the individual, outbursts significantly decrease in a group home setting for individuals with TBI (Denmark & Gemeinhardt, 2002). Traditionally, behavior therapy has focused on modification of maladaptive behaviors. However, it has also been effective in helping individuals to relearn other skills such as self-care, budgeting, etc.

Terms and Concepts in Behavior Therapy

Identifying and modifying antecedents

As mentioned previously, analyzing the environment for antecedents to problem behavior and adapting the environment in which the behavioral problems occur can be critical in decreasing the severity and frequency of the behavior. For instance, an outburst could be preceded by a lot of noise, too many people in the room, too many demands, or simply fatigue or hunger (Ponsford, 1995). In the initial stages of working with an individual with TBI and assessing reasons for undesirable behaviors, consider the environment’s comfort and pleasantness, level of stimulation, and adequacy in terms of privacy. Consider cultural issues that may contribute to behavioral problems. For instance, most Europeans prefer to bathe rather than shower. Attempting to impose a change in these cultural practices may, in fact, cause an undesirable behavior to occur. External expectations that do not take these issues into account may become a source of frustration for the individual and can contribute to behavioral problems.

Fluharty and Glassman (2001) examined the use of antecedent control to improve outcome for an individual with frontal lobe injury and intolerance for auditory and tactile stimuli. The individual suffered from profound memory, reasoning, and insight deficits. Therefore, traditional behavior modification using reinforcement and consequences was unsuccessful. The individual was unable to recall what behavior resulted in reward or consequence and had limited ability to understand the effects of his behavior. The treatment team made changes to the environment by eliminating noise and touch, which had previously served as triggers for problem behaviors. These changes were effective in reducing the problem behaviors. Clearly, understanding antecedents is a very important factor in the process of changing behavior.

Identifying and modifying consequences

Consequences serve to encourage or discourage a specific behavior or behavioral pattern. For example, others’ reaction to an unwanted behavior may impact the individual’s response resulting in the escalation (or de-escalation) of the behavior. This is referred to as an integrated experience — both individuals’ behavior and attitude affect each other (Caraulia & Steiger, 1997). Individuals who display maladaptive behaviors are the most challenging to rehabilitate and may be excluded from rehabilitation settings because staff members lack the skills to respond effectively. If participating in a program that does not specialize in the treatment of maladaptive behavior, there is a natural tendency for staff to intensify interactions with the individual during the crisis situation (or when maladaptive behavior is exhibited) and to provide less attention to the individual when he/she is not displaying the maladaptive behaviors. The attention paid to the maladaptive behavior becomes a rewarding or reinforcing consequence. According to Alderman (2003), a benefit of using behavior therapy techniques is that staff members are required to attend to the individual when he/she is displaying desired, productive behaviors, reversing the tendency to attend to undesirable behaviors.

Positive reinforcement

Positive reinforcement refers to the use of rewards, privileges, incentives, attention, and praise to increase a desired behavior. When positive things happen following a behavior, the behavior is likely to increase.

Negative reinforcement

Negative reinforcement refers to the removal of noxious stimuli in order to increase desired behavior. For example, when inappropriate or aggressive behavior successfully stops the continuation of an unpleasant or physically taxing physical therapy session (unpleasant stimuli), the inappropriate or aggressive behavior is likely to occur in the future (Braunling-McMorrow, Niemann, & Savage, 1998).

Punishment

Punishment consists of unpleasant consequences following undesirable behavior. When behavior leads to a negative consequence (punishment), it is less likely to occur (Braunling-McMorrow, et al., 1998). It should be noted that punishment is consistently found to be less effective than positive reinforcement for creating and maintaining behavioral change. When the threat of the punisher has been removed, the behavior may resume.

Differential reinforcement

Differential reinforcement refers to a variety of positive reinforcement strategies and is one of the most widely used concepts in behavior therapy. The primary focus of differential reinforcement is to positively reinforce a desirable behavior that will replace the undesirable behavior. Four categories of differential reinforcement are defined below with an example as described in the American Academy for the Certification of Brain Injury Specialists (AACBIS) Training Manual for Certified Brain Injury Specialists (Braunling-McMorrow et al., 1998).

  • Differential Reinforcement of Other Behavior (DRO) – In using DRO, the individual receives a reward for specified periods of time in which there has been no occurrence of the undesirable behavior. For example, someone who has a verbal outburst twice per hour would receive a reward for each 30-minute interval in which no verbal outbursts occur.
  • Differential Reinforcement of Incompatible Behavior (DRI) — In DRI, a behavior that is incompatible with the undesirable behavior is identified and reinforced. For example, if one touches others repetitively when asked not to do so, an incompatible behavior would be keeping one’s hands in one’s pockets. The individual would receive positive reinforcement when engaging in the incompatible behavior.
  • Differential Reinforcement of Alternative Behavior (DRA) — DRA involves identifying an alternative behavior that is not necessarily incompatible with the target behavior and reinforcing it. For example, if one is overly talkative during vocational activities, an alternative behavior (e.g., remaining on task) is reinforced, while the undesirable behavior (e.g., talking) is ignored.
  • Differential Reinforcement of Low-Rate Behavior (DRL) — DRL involves the reinforcement of the reduction of undesirable behavior. For example, if someone displays 20 verbal outbursts per day, it is unrealistic to implement a plan that requires zero verbal outbursts to earn reinforcement. Rather, implementing a plan in which a lower frequency of the undesirable behavior, (i.e., displaying no more then 15 verbal outbursts per day), is more realistic. When the individual displays a lower rate of an unwanted behavior, reinforcement is provided.

Individual Behavior Plans

Reinforcement systems may be combined to develop an individual behavior plan. Individual behavior plans are detailed plans that include strategies and interventions designed to address specific issues that are impeding an individual’s progress toward goals. The plan takes into account the individual’s strengths and weaknesses and individual learning style. Since precision and consistency of application is important for learning to occur and for new behavioral patterns to develop, scripts are incorporated into the plan. A script is a set of written instructions that direct individuals working with the person with brain injury on how to respond to certain behaviors or situations. A behavior plan addresses antecedents and consequences. It defines a way of responding that teaches, elicits, and reinforces adaptive behavior, minimizes reinforcement of maladaptive behavior, and ensures the safety of the individual. Prompts, cues, instructions, and gestures are used to elicit the desirable behavior that is subsequently reinforced. Verbal instructions, visual cues (pictures), physical guidance (hand-overhand), and modeling can be used to facilitate learning (Wood, 2001). Verbal mediation is another method used to elicit adaptive behavior. Verbal mediation is used when the precursors of maladaptive behavior become evident. Mediation is used to evoke thoughts (why am I feeling this way?) and problem solving (alternatives in dealing with the problem situation). In the area of non-violent crisis intervention, Caraulia and Steiger (1997) developed a verbal mediation strategy that is called CPI COPING. COPING stands for: recognition of lack of “control” which prompts the following sequence: “orient” the person to the facts, identify “patterns” of behavior, “investigate” alternatives to the behavior, “negotiate” using a behavioral or incentive plan, and “give” back empowerment. While its development was not geared specifically to individuals with TBI, several of the steps have been useful when practicing verbal mediation with individuals with TBI. When prompting or verbal mediation elicits adaptive behavior, the behavior is reinforced.

Specific reinforcers or rewards must be identified for the individual for whom the plan is being developed. Remember, we are all unique in our preferences and what one person may find reinforcing or rewarding may not be reinforcing for another. To identify preferences for reinforcers, can ask the individual, ask family or friends, or simply observe the individual. Primary reinforcers include, but are not limited to, praise, encouragement, and attention. Secondary reinforcers such as tokens or points may be earned and traded in for special outings, increased time in certain activities or with preferred individuals, or desired purchases. Rewards may be provided each time the desired behavior occurs or at scheduled times such as at the end of the day. Cognitive factors may influence the schedule of reinforcement (ResCare Premier, 2002). For example, memory problems may interfere with the effectiveness of a reward program that involves a lengthy delay; the individual may not recall what they did or didn’t do to obtain the reward. Alternatively, rewards given too frequently may result in the individual becoming satiated. The frequency of delivery of reinforcers must be identified in the behavior plan.

One type of secondary reinforcement system used within rehabilitation settings is the “token economy.” Ponsford (1995) recommends that a psychologist supervise this type of system. The individual may receive tokens as reward for desired behavior; they may then exchange the tokens for certain material rewards. A set of rules is established outlining the behaviors desired, the frequency with which the tokens may be earned, and how they can be exchanged. Tokens can be given immediately or at specified time intervals. A specified time interval is effective if you are teaching the individual to remain on task or to sustain learned behavioral changes. Difficulties with this system have been noted by Ponsford (1995) who points out that some individuals with TBI find the system demeaning. Therefore, she suggests that a point system be implemented instead. The points are earned, similar to tokens; praise and encouragement is provided at the time that points are awarded. The point system is very effective for both individuals with TBI and staff members as it increases both parties’ awareness of the expected behavior. The system promotes consistency and provides the opportunity for social reinforcement. Both token and point systems provide a visual cue so the individual can monitor his/her progress and successes throughout the day. Incentive programs such as point or token systems are used successfully to encourage participation in rehabilitation activities and development of adaptive behavior.

In addition to incentive programs, incidental and structured feedback may be incorporated into a behavior plan. Incidental feedback involves providing a prescribed response at the time that the alternative, adaptive behavior is observed. Structured feedback is a review with the individual of recent events or activities that have occurred. An individual may not have insight into what happened and why. Structured feedback provides an opportunity to get the facts and to analyze elements of the intervention plan that may not be working. The process can be a learning opportunity, an opportunity to develop preventive strategies for the future, and can be helpful in developing self monitoring skills. The review may occur at intervals throughout the day (at lunch, dinner, etc.). Each interval’s activities or events are reviewed.

Schlund and Pace (1999) conducted a study to examine the benefit of systematic feedback to reduce maladaptive behaviors in three individuals with TBI. Their study concluded that the implementation of this feedback resulted in a reduction of both the variability and frequency of maladaptive behavior.

Summary of guidelines for an individual behavior plan

The following are guidelines for implementing a successful behavior plan (Alderman, Davies, Jones, & McDonnel, 1999; Braunling-McMorrow, 1998; Ponsford, 1995; ResCare Premier, 2002; Wood, 2001).

  • The individual with TBI should be included in the development, design, and implementation of the behavior plan. If the individual has input into the plan, it increases motivation to participate.
  • The behavior targeted for change should be identified and clearly defined.
  • The alternative behavior to be reinforced must be identified and clearly defined.
  • Scripts and directions for teaching and eliciting the adaptive behavior should be included.
  • Types and timing of reinforcement should be defined. The plan should be as positive as possible. The focus of a behavior change plan should be on teaching and rewarding desired behavior. Rehabilitation is a difficult process. Encouragement and praise should be given liberally for all attempts to complete the desired behavior.
  • It is a misconception that punishment or loss of privileges is the most effective response to undesirable behaviors. Punishment should be used only after all other interventions have been attempted and exhausted and when the maladaptive behavior is extreme, putting the person or those in his/her environment at risk. If this type of intervention is necessary, all stakeholders (family, rehabilitation providers, funders, case managers, etc.) must be in agreement in regard to the strategy used. The strategy is then used in conjunction with incentives for positive behaviors.
  • The plan should be a tool for teaching. Some individuals may display ‘avoidance’ and ‘escape’ behaviors. When a demand is initiated, individuals with TBI may respond by acting out in order to escape the task. However, being proactive and teaching alternative behaviors can help the individual to cope with the task. For example, identify the skills needed to complete the avoided task, teach the skills to the individual in small, manageable steps, develop an advance agreement to complete the avoided task at a specified time thereby giving the individual the ability to prepare for the task, and follow task completion with a positive reinforcer to increase the likelihood that the desirable response will occur.
  • The plan should be carried out in all contexts. Behavior does not happen in a vacuum, it is influenced by environmental factors and therefore can be displayed in the home, in the community, in the rehabilitation setting, etc. Consistency in implementing the program is critical for its success. Any inconsistencies may cause confusion and may indirectly reinforce the undesirable behavior. All individuals implementing the plan should receive training in all aspects of the plan.
  • The plan should include opportunities for feedback.
  • The frequency in which the desired and undesired behavior occurs should be documented. This process serves two purposes. First, tracking behavioral frequency provides feedback for the individual regarding his/her progress. Second, by tracking behavioral patterns, the effectiveness of the individual behavior plan can be evaluated and revised as needed. It may be necessary to adjust expectations if the desired behavior is too easy or too difficult or to adjust the frequency or type of rewards.

Relaxation Training

Relaxation training is used to reduce one’s experience of anger and tension (Denmark & Gemeinhardt, 2002). It is thought that an individual cannot exhibit both relaxation and anger/tension responses at one given time. Therefore, the individual learns relaxation strategies that he/she can implement when feelings of anger/tension emerge in daily life. Some examples of these techniques are progressive muscle relaxation (focused relaxation of each muscle group in the body — feet, legs, torso, etc.), guided imagery (visualizing relaxing, peaceful, or encouraging experiences), biofeedback (monitoring the relaxation response by using electrodes which monitor and provide feedback about the activity of a muscle), breathing exercises, and forms of meditation (Denmark & Gemeinhardt, 2002). It is useful to incorporate role-play into relaxation sessions. The individual practices initiating relaxation techniques while thinking about potential real-life situations. There is very little literature that evaluates outcomes for the use of relaxation therapy techniques for individuals with TBI. This technique, however, has been used with success for individuals with learning disabilities and for children (Denmark & Gemeinhardt, 2002).

Social Skills Training

Social skills training programs are implemented with individuals who lack interpersonal skills and the ability to effectively communicate their desires in a problem situation or conflict (Denmark & Gemeinhardt, 2002). This type of program is geared toward individuals with problems in social interactions and includes focus on the development of social skills, assertiveness, and problem solving techniques. Social skills acquisition includes teaching the individual how to listen and understand others. Assertiveness teaches the individual to express him/herself constructively rather than in a confrontational manner. Problem-solving techniques allow the individual to develop conflict resolution skills. For individuals with TBI, this type of training can be especially useful as many individuals have difficulty expressing themselves, which often results in frustration and maladaptive responses. Denmark and Gemeinhardt (2002) suggest that role modeling the problem situations in a safe environment is the most beneficial. The role-playing allows the individual to learn appropriate responses or strategies at his/her own rate. It also provides opportunities for repetition and rehearsal of skills. The individual is able to internalize the behavior which helps to circumvent cognitive deficits such as planning, sequencing, and comprehension.

Anger Management

Novaco (1975) introduced one of the first multi-component approaches to anger management. He used a combination of behavioral, relaxation, and assertiveness training during three phases of treatment. The three phases included: 1) cognitive preparation, 2) skill acquisition, and 3) application of training. Medd and Tate (2000) conducted a study with persons with brain injury using a variation of Novaco’s principles. They modified the training by outlining anger syndromes and common difficulties relevant to TBI and developed handouts summarizing the sessions. The program encouraged the participants to increase their awareness of emotional, behavioral and cognitive changes that occur when they become angry. The participants practiced relaxation techniques, self talk methods, and time outs. Medd and Tate (2000) concluded that this type of intervention was beneficial to the individuals in their study. However, they also recognized that the individuals in their study had a relatively high level of cognitive ability with only minimal memory impairments noted. They questioned the effectiveness of this type of approach with individuals who had more severe cognitive impairments.

Another multicomponent anger management program was developed by Deffenbacher (1995) and was called ideal treatment package. This included assessing the individual’s anger and then working at developing self-monitoring, stimulus and response control, relaxation, cognitive restructuring, and interpersonal skills (Denmark & Gemeinhardt, 2002). A study has not been conducted to date regarding the application of this program with individuals with TBI.

Conclusion

In conclusion, several therapeutic approaches exist to assist individuals with brain injury to develop adaptive behaviors. At this time, there is not enough outcome data to dictate which therapy works best. The challenge for those who work with persons with brain injury is to find the intervention or combination of intervention strategies that works best for each individual. It is unlikely that one approach will ever be the ‘sole treatment’ for behavioral problems following brain injury. Unique individuals require unique and individualized treatment.

References

Albert Ellis Institute, & Abrams, M. (2004). Retrieved May 17, 2004, from Albert Ellis Institute Web site: http://www.rebt.org.

Alderman, N., Davies, J. A., Jones, C., & McDonnel, P. (1999). Reduction of severe behavior in acquired brain injury: Case studies illustrating clinical use of the OAS-MNR in the management of challenging behaviors. Brain Injury, 13(9), 669-704.

Alderman, N. (2003). Contemporary approaches to the management of irritability and aggression following traumatic brain injury. Neuropsychological Rehabilitation, 13(1/2), 211-240.

Bennet, T. L., & Raymond, M. J. (1997). Emotional consequences and psychotherapy for persons with traumatic brain-injury: Management of frustration and substance abuse. Journal of Head Trauma Rehabilitation, 13(6), 10-22.

Braunling-McMorrow, D., Niemann, G.W., & Savage, R. (Eds.). (1998). Training manual for the certified brain injury specialist (CBIS) (2nd ed.). Houston, TX: HDI Publishers.

Caraulia, A. P., & Steiger, L. K. (1997). Nonviolent crisis intervention: Learning to diffuse explosive behavior. WI: CPI Publishing.

Deffenbacher, J. L. (1995). Ideal treatment package for adults with anger disorders. In: H. Kassisnove (Ed.), Anger disorders: Definition, diagnosis, and treatment (151-172). Washington D.C.: Taylor & Francis.

Denmark, J., & Gemeinhardt, M. (2002). Anger and its management for survivors of acquired brain injury. Brain Injury, 16(2), 91-108.

Ellis, A., & Dryden, W. (1997). The practice of rational emotive behavior therapy (2nd ed.). New York: Springer.

Fluharty, G., & Glassman, N. (2001). Use of antecedent control to improve the outcome of rehabilitation for a client with frontal lobe injury and intolerance for auditory and tactile stimuli. Brain Injury, 15(11), 995-1002.

Kinney, A. (2001). Cognitive therapy and brain injury: Theoretical and clinical issues. Journal of Contemporary Psychotherapy, 31(2), 89-102.

Manchester, D. & Wood, R. L. (2001). Applying cognitive therapy in neuropsychological rehabilitation. In R. L. Wood & T. M. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury. Hove, England: Psychology Press.

Medd, J., & Tate, R. L. (2000). Evaluation of an anger management therapy programme following acquired brain injury: A preliminary study. Neuropsychological Rehabilitation, 10(2), 185-201.

Novaco, R. W. (1975). Anger Control. Lexington, KY: D.C. Health.

Pologe, B. (2001). About psychotherapy. Retrieved March, 2004, from http://www.aboutpsychotherapy.com.

Ponsford, J. (1995). Traumatic brain injury: Rehabilitation for everyday adaptive living. Hove, England: L. Erlbaum Associates.

Prigatano, G. P. (1986). Psychotherapy after brain injury. In G. P. Prigatano, D. J. Fordyce, H. K. Zeiner, J. R. Roeche, M. Pepping, & B .C. Woods (Eds.), Neuropsychological rehabilitation after brain injury. Baltimore: John Hopkins University Press.

ResCare Premier. (2002, June 19). Developing individual behavior plans [CO.Beh.401]. In Training, education, and mentoring system. St. Louis, MO: R. Estes (Ed.).

Schlund, M. W. & Pace, G. (1999). Relations between traumatic brain injury and environment: Feedback reduces maladaptive behavior exhibited by three persons with traumatic brain injury. Brain Injury, 13(11), 889-897.

White, S. M., Seckinger, S., Doyle, M., & Strauss, D. L. (1997). Compensatory strategies for people with traumatic brain injury. NeuroRehabilitation, 9, 205-212.

Wood, R. L. (2001). Neurobehavioral disorders: Their origin, nature and rehabilitation. Seminar provided at the meeting of the Ontario Brain Injury Association in conjuction with Brock University, St. Catharines, Ontario.

Wood, R. L., & Worthington, A. D. (2002). Neurobehavioral rehabilitation: a conceptual paradigm. In R. L. Wood & T. McMillan (Eds.), Neurobehavioral disability and social handicap following traumatic brain injury (107-132). Hove, England: Psychology Press.

Posted on BrainLine June 22, 2009.

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[WEB SITE] What’s the Difference Between CBT and DBT?

Whats the Difference Between CBT and DBT?Cognitive-behavioral therapy (CBT) is one of the most commonly practiced forms of psychotherapy today. It’s focus is on helping people learn how their thoughts color and can actually change their feelings and behaviors. It is usually time-limited and goal-focused as practiced by most psychotherapists in the U.S. today.

Dialectical behavior therapy (DBT) is a specific form of cognitive-behavioral therapy. DBT seeks to build upon the foundation of CBT, to help enhance its effectiveness and address specific concerns that the founder of DBT, psychologist Marsha Linehan, saw as deficits in CBT.

DBT emphasizes the psychosocial aspects of treatment — how a person interacts with others in different environments and relationships. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT was originally designed to help treat people with borderline personality disorder, but is now used to treat a wide range of concerns.

DBT theory suggests that some people’s arousal levels in certain situations can increase far more quickly than the average person’s. This leads a person to attain a much higher level of emotional stimulation than normal, and it may take a significant amount of time to return to normal emotional arousal levels.

DBT differs in practice in one important way. In addition to individual, weekly psychotherapy sessions, most DBT treatment also features a weekly group therapy component. In these group sessions, people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills. A group setting is an ideal place to learn and practice these skills, because it offers a safe and supportive environment.

Both CBT and DBT can incorporate exploring an individual’s past or history, to help an individual better understand how it may have impacted their current situation. However, discussion of one’s past is not a focus in either form of therapy, nor is it a differentiation between the two forms (it is completely dependent upon the individual psychotherapist).

Whether cognitive-behavior therapy or dialectical behavior therapy is right for you is a determination best made in conjunction with an experienced therapist. Both types of psychotherapy have strong research backing and have been proven to help a person with a wide range of mental health concerns.

via What’s the Difference Between CBT and DBT?

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[WEB SITE] Understanding the Anxious Brain

Post by D. Chloe Chung
“I was so anxious to do what is right that I forgot to do what is right.” – Jane Austin

What’s the deal with anxiety?

You’re giving an important presentation tomorrow for work in front of a big crowd. You know you’re well-prepared, but when you imagine yourself standing at the podium, facing strangers whose eyes are fixed on you, you start to feel nauseated – your palms sweat and your heart hammers in your chest. You’re experiencing acute anxiety, a state of negative emotions and heightened arousal, often accompanied by increased alertness. This definition may sound similar to that of ‘fear’, which is produced as an acute response to immediate threats. There is considerable overlap between the brain circuitry regulating anxiety and fear, but anxiety is distinct from fear because it can be internally triggered or anticipatory – just like when you were merely imagining that presentation for work. Much of our understanding of anxiety stems from what we have learned about how the brain processes and learns fear responses.

What’s going on in your brain when you’re feeling anxious?  

Recent research efforts have emphasized the importance of communication between multiple brain areas in evoking anxiety. One of the established models of the neural circuitry of anxiety proposes that anxiety arises due to active neural communication between brain regions, including the amygdala, a brain structure involved in fear learning. The amygdala (the central extended amygdala [CeA]) sends projections to the bed nucleus of the stria terminalis (BNST), a cluster of nuclei involved in threat monitoring. The amygdala and the BNST also communicate with other brain regions such as the ventral hippocampus (vHPC) and the prefrontal cortex (PFC). According to this model, these four regions are connected by neural projections and work with one another in an orchestrated manner to evaluate whether or not a situation is threatening. The brain activity in this group of regions that we’ll refer to as the ‘anxiety detection’ regions can be either anxiogenic or anxiolytic, meaning they can perpetuate or reduce anxiety, respectively.


Downstream, the motor cortex, regions of the brainstem, and the neuroendocrine system receive, interpret, and evaluate possible anxiety signals from the brain regions involved in anxiety detection. These downstream regions then initiate anxiety responses by triggering defensive and risk-avoiding behaviors and altering biological functions such as heart and respiration rate. Excessive anxiety can occur when the brain’s anxiety pathways misinterpret incoming signals. For instance, repeated exposure to ‘threatening’ situations may cause anxiogenic pathways to become abnormally hyperactive, and therefore more sensitive to threatening stimuli. This can cause an imbalance in the neural circuitry that processes anxiety, shaping the brain to become more reactive and susceptible to experiencing anxiety.

What’s new in anxiety research?

While we know the amygdala (specifically the CeA) is particularly important for anxiety regulation, the exact mechanisms are difficult to disentangle. Recent research has helped to shed light on some of the specific circuitry involved. A recent study in the Journal of Neuroscience used a novel rat model and deleted a gene called ErbB4 –  implicated in various neurological disorders  in a group of amygdala neurons that release somatostatin, a peptide implicated in fear responses. In behavioral tests, rats without this gene exhibited higher anxiety levels, due to increased somatostatin levels in the amygdala. The abnormal activity of somatostatin neurons in the CeA also disrupted the inhibition of somatostatin neurons in the BNST, rendering these neurons hyperactive and ultimately causing heightened anxiety. A peptide called dynorphin has been identified as a key molecular player in this amygdala-BNST anxiety circuit. The authors demonstrated that the amount of dynorphin produced by somatostatin neurons in the amygdala was increased, and led to disinhibition of the BNST, contributing to the induction of anxiety-related behaviors. In other words, both somatostatin and dynorphin work together to play an important role in increased anxiety in mice without ErbB4. The good news is that dynorphin could be a potential target for anxiety treatment.

Another area of anxiety research concerns the stress neuropeptide, corticotropin-releasing factor. It’s known to regulate the BNST’s ability to elicit anxiety, but it was unclear where the corticotropin-releasing factor was coming from until recently. A study published by Pomrenze et al. showed that corticotropin-releasing factor is majorly produced and released by a group of neurons located in the lateral amygdala and the dorsolateral BNST. Using designer drugs that can either inhibit or activate neurons expressing the corresponding receptors via viral transduction, the authors found that neurons that project from the lateral amygdala to the BNST and release corticotropin-releasing factor are critical in mediating anxiety. Removal of these neurons reduced anxiety behaviors, confirming the importance of corticotropin-releasing factor in evoking anxiety responses.

What happens when anxiety interferes with daily life?

Modern life is full of stressors and many people are prone to experiencing intense anxiety at some point in their lives. In fact, anxiety is a part of a normal emotional spectrum and can even be beneficial at times, increasing our vigilance and enabling our survival. However, chronic anxiety can severely interfere with day-to-day living and become pathological, resulting in generalized anxiety disorder (GAD) or other anxiety-related disorders. Anxiety disorders like GAD are common, impacting one in every five adults. Considering how many individuals are affected by pathological anxiety, there is a need for highly effective anti-anxiety drugs or behavioral interventions. It is critical to understand the brain circuitry underlying anxiety to develop effective treatment options for chronic anxiety disorders.

Since anxiety results in heightened arousal, many anxiety medications manipulate neurotransmitters to slow the nervous system down, decreasing arousal. Medications such as selective serotonin reuptake inhibitors (SSRIs) and Buspirone work to increase serotonin in the nervous system, which can, in turn, decrease arousal. Medication options for phobias such as social anxiety tend to decrease the effect of norepinephrine, a neurotransmitter connected to the ‘fight or flight’ fear response. Cognitive-behavioral therapy (CBT) and consulting with certified therapists can also improve anxiety. CBT is a popular and effective strategy that guides individuals to replace anxiety-provoking interpretations of situations with benign ones. For individuals with less severe anxiety symptoms, CBT can sometimes work as well as some medications, depending on the person and the extent of their anxiety. CBT can also be combined with other therapeutic approaches to effectively treat anxiety depending on the severity of symptoms. Regular physical exercise and breathing exercises can also be effective in reducing anxiety symptoms.

Things to remember about anxiety

To manage acute daily anxieties, remembering how the brain circuitry of anxiety works might be helpful – the anxiety regions of the brain first assess whether the situation is threatening or not, and then subsequently trigger the anxiety response. This means that we can practice psychological tricks to aid the brain in better assessing non-threatening situations as just that – non-threatening. Similar to CBT, by taking a step back and evaluating the situation, we can develop habits that lead to new responses and potentially avoid an unnecessary anxiety response in the future. Making an effort to be aware of our anxious thoughts or worries and replacing them with more realistic ones can also be beneficial in helping our brain to relearn our responses to potentially threatening situations. Since the human brain is plastic (i.e. it adapts to changes in our internal and external environments), conscious efforts can result in a shift in the anxiety circuitry. Another key factor in mitigating anxiety is an awareness of the surrounding environment. Anxiety-inducing neural circuitry can be over-activated when we’re repeatedly exposed to certain stressors in our environment, resulting in feelings of anxiety in situations that are not immediately threatening. Hence, eliminating or minimizing such stressors in our environment can help.
Calhoon GG, Tye KM. Resolving the neural circuits of anxiety. Nature Neuroscience (2015) 18(10): 1394-404. DOI: 10.1038/nn.4101.

Ahrens S, Wu MV, Furlan A, Hwang GR, Paik R, Li H, Penzo MA, Tollkuhn J and Li B. A central extended amygdala circuit that modulates anxietyJournal of Neuroscience (2018) 38(24): 5567-5583. DOI: 10.1523/JNEUROSCI.0705-18.2018

Pomrenze MB, Tovar-Diaz J, Blasio A, Maiya R, Giovanetti SM, Lei K, Morikawa H, Hopf FW and Messing RO. A corticotropin releasing factor network in the extended amygdala for anxiety. Journal of Neuroscience (2019) 39(6): 1030-1043. DOI: 10.1523/JNEUROSCI.2143-18.2018

Hofmann SG, Asnaani A, Vonk IJJ, Sawyer AT, and Fang A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research (2012) 36(5): 427-440. DOI: 10.1007/s10608-012-9476-1

Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in Cinical Neuroscience (2015) 17(3):337-46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610618/

via BrainPost Life: Understanding the Anxious Brain

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[Abstract] Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation

Abstract

Background: Early rehabilitation after stroke is essential to help reduce disability.
Purpose: To summarize evidence on the benefits and harms of nonpharmacologic and pharmacologic treatments for motor deficits and mood disorders in adults who have had stroke.
Data Sources: English-language searches of multiple electronic databases from April 2009 through July 2018; targeted searches to December 2018 for studies of selective serotonin reuptake inhibitors (SSRIs) or serotonin–norepinephrine reuptake inhibitors.
Study Selection: 19 systematic reviews and 37 randomized controlled trials addressing therapies for motor deficits or mood disorders in adults with stroke.
Data Extraction: One investigator abstracted the data, and quality and GRADE assessment were checked by a second investigator.
Data Synthesis: Most interventions (for example, SSRIs, mental practice, mirror therapy) did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported use of cardiorespiratory training to improve maximum walking speed and repetitive task training or transcranial direct current stimulation to improve activities of daily living (ADLs). Low-quality evidence supported use of robotic arm training to improve ADLs. Low-quality evidence indicated that antidepressants may reduce depression, whereas the frequency and severity of antidepressant-related adverse effects was unclear. Low-quality evidence suggested that cognitive behavioral therapy and exercise, including mind–body exercise, may reduce symptoms of depression and anxiety.
Limitation: Studies were of poor quality, interventions and comparators were heterogeneous, and evidence on harms was scarce.
Conclusion: Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation may improve ADLs in adults with stroke. Cognitive behavioral therapy, exercise, and SSRIs may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported.
Primary Funding Source: U.S. Department of Veterans Affairs, Veterans Health Administration.

via Treatments for Poststroke Motor Deficits and Mood Disorders | Annals of Internal Medicine | American College of Physicians

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[Infographic] COGNITIVE BEHAVIORAL THERAPY Facts

Cognitive behavioral therapy facts - Dr. Axe

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[WEB SITE] Quiz: What Type of Therapy is Best for You?

Quiz: What Type of Therapy May Be Best for You?

Medically reviewed by psychologist Sarah Schewitz, Psy.D.

Walking into therapy for the first time can feel a little like walking into “The Twilight Zone.” It’s hard to know what to expect and intimidating to think you’ll be sharing so much information with a stranger. Not to mention, each type of therapy has its own guidelines and perspective. And, while the relationship you have with your clinician is perhaps the most important indicator of how well therapy will work for you, not every type of therapy will be a good fit.

Before booking your first therapy session or enrolling in a program, it’s a good idea to find out how your new therapist might meet your needs. After all, you don’t want to be stuck in a room with a counselor whose thoughts on what’s going on for you just don’t jive at all with your experience. Plus, doing a little legwork ahead of time to match the type or types of therapy a counselor uses can help you determine who you might have the best relationship with.

Although some professionals and programs strictly adhere to one type of therapy, many now use several different types of therapy to work with clients. This lets them borrow important skills from each type to better serve your needs. These therapists consider themselves integrative or even eclectic. Keep this in mind as you’re looking for therapist — and taking the following quiz.

This quiz is not professional or medical advice, but simply a way to introduce you to some of the more common types of therapy out there — these are only four of dozens of options. Your results from this quiz will help guide you to what type of therapy may be a good fit for you.

Don’t be worried about answering the questions perfectly. There are no wrong answers. When you are finished with the quiz you will receive your match. For more information on each type of therapy, check below the quiz for more information and where you can find counselors who use those skills in their practice.

Without further ado, visit WEB SITE to TAKE the QUIZ

Cognitive Behavioral Therapy (CBT)

It’s been said what you think is who you are. Just ask Ralph Waldo Emerson, Mahatma Gandhi — or even the Bible. Cognitive behavioral therapy (CBT) borrows a little from this concept: By changing your thoughts, you can also change your emotions and behaviors for a more satisfying life.

In the CBT world, your current thoughts, emotions and behaviors interact with each other. By addressing thoughts that don’t help you, CBT therapists believe you’ll start to experience more well-being. Typically, CBT doesn’t delve way back into your childhood and it’s a format that might include homework, like keeping a log of unhelpful thoughts that might pop into your head that make you feel depressed. It’s skills-based and action-oriented, so this is a good fit if you like to get things done efficiently and in a shorter amount of time — CBT therapy is usually completed in less than 20 sessions.

Because CBT is generally very structured and focuses on concrete, in-the-moment skills, it’s especially helpful if you’re dealing with an anxiety or panic disorder, a specific phobia or obsessive-compulsive disorder (OCD). Many people with depression, suicidal ideation or self-harm, substance use disorders and eating disorders also find CBT helpful. If you live with chronic pain, your treatment team may recommend CBT because it can help you accept the pain you can’t change and learn new coping skills.

You can find CBT therapists through the Association for Behavioral and Cognitive Therapies (ABCT) or Academy of Cognitive Therapy websites.

Dialectical Behavioral Therapy (DBT)

If things feel out of control and super intense — your emotions, relationships, even sometimes your behaviors — dialectical behavior therapy (DBT) is designed with exactly that in mind. This form of therapy focuses on four main areas to help you master your well-being, including mindfulness, distress tolerance, emotion regulation and interpersonal relationships.

DBT was created to treat borderline personality disorder (BPD) and those who struggle with persistent suicidal thoughts or self-harm. One of DBT’s strengths is it gives you a toolbox full of useful life skills so you feel more in control, especially when you didn’t learn those basic emotion regulation or relationship skills earlier in life. DBT is also useful if you’re dealing with other mental health conditions like post-traumatic stress disorder (PTSD), substance use disorders and eating disorders, among others.

There are a couple ways you can do DBT. The traditional, full program includes individual sessions with a DBT therapist, a weekly group skills class and phone coaching between sessions. This can get expensive, so you can also look for a therapist with training to incorporate DBT skills into your regular sessions or participate in just a group skills class.

In whatever context you try DBT, be prepared to work. Studies show DBT can be incredibly effective but you’ll have homework, be expected to track your progress and practice your skills regularly. And know DBT is full of acronyms that might seem overwhelming at first, but soon you’ll be PLEASE-skilling and DEAR MAN-ing like a pro.

To find a DBT therapist near you, search the directories on Behavioral Tech or DBT-Linehan Board of Certification.

Psychodynamic

The premise of psychodynamic therapy is very much based in exploring how the current issues you are dealing with and who you are today originated from your early experiences. By talking through the free associations that come to mind from your past, present, future and dreams, you work with a therapist to find meaning and understanding from your history. These therapists especially focus on their relationship with you, and, traditionally, they use their reactions to you and relationship with you as another tool to help you understand yourself. Relationship is key in psychodynamic formats.

If you’re not a fan of a strict format or homework, are drawn to almost exclusively talk therapy and want to focus on how your past affected you, the more free-flowing nature of psychodynamic therapy may be a good fit for you. Over the years research has shown psychodynamic therapies can help with a variety of mental health conditions, particularly if you’ve experienced trauma.

However, because of the more open format of psychodynamic therapy, if you’re struggling with suicidal thoughts or an active substance use or eating disorder, traditional psychodynamic therapy might not be a good idea. A more structured, skills-based therapy might be needed to make sure you’re safe first. If you still want to work with a psychodynamic therapist in these instances, be sure to ask if they also have training in skills designed to keep you safe during higher-risk times in your life.

Find a psychodynamic therapist near you on Psychology Today.

Interpersonal Psychotherapy (IPT)

If you want to approach your mental health from a well-rounded perspective that takes into account your physical, social, emotional and spiritual health, you might be drawn to interpersonal psychotherapy (IPT). Its major tenant suggests struggles in your interpersonal relationships are directly connected to your mental health symptoms. IPT also believes in the medical model of mental illness, so if you often find yourself comparing dealing with a mental illness to a physical illness, IPT might suit you.

This type of therapy focuses mostly on the present and not on therapy itself, but your life in the real world. IPT is very structured and lasts a set amount of time, usually 12 to 16 sessions. It’s based on attachment — the idea your connections with others is one of the most important aspects of your emotional health. By examining and exploring issues in your current relationships, an IPT therapist works to help you develop stronger connections to reduce your mental health symptoms. This work is done using techniques like role-playing and analyzing how you communicate.

IPT was originally created to treat major depressive disorder and studies also found it’s effective for conditions like anxiety and eating disorders. It’s also helpful when you’re moving through transitions in your life, like a divorce, a move to a new city or a new job. This form of therapy can be used in group therapy settings as well.

You can search for an interpersonal psychotherapist near you on Psychology Today.

If there’s a specific type of therapy you want to try, it may be hard to find a professional in your area that’s affordable and available. If you’re having a hard time finding a local therapist, you’re not alone. You can call the National Alliance on Mental Illness (NAMI) Helpline for assistance finding mental health treatment resources in your area, including therapy and group support. Mental Health America also provides a resource list for other ways you can find referrals and mental health resources.

via Quiz: What Type of Therapy is Best for You? | The Mighty

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[WEB SITE] VRHealth unveils VR software for hot flashes

The new technology will provide users with an AI guide that will lead them through CBT.

By Laura Lovett, December 12, 2018

Photo credit: VRHealth

 

VRHealth has exclusively unveiled to MobiHealthNews a virtual reality product called Luna that was designed to help patients manage hot flashes.

The new VR product, which can be used by patients going through menopause or chemotherapy treatment, employs cognitive behavioral therapy (CBT). It also gives users a data analysis of their treatment.

When a user puts on the VR headset, they are greeted by an AI trainer called Luna who guides users through CBT and other coping mechanisms. The technology also lets users virtually travel to another environment.

“That trainer you can take to different places. One part of the app is called practice breathing in an environment. It [let’s you] see how you breath,” Eran Orr, CEO of VRHealth, told MobiHealthNews. “Users can actually see the environment and go into a lake or waterfall.”

While the technology will first be given to patients in a hospital setting, Orr said that the idea is for the system to go home with the patients.

“Patients will be introduced to it during chemotherapy or treatment in the hospital and will take [the] headset back home,” he said. “It is an AI that is basically a trainer that follows improvement and can be adjusted automatically.”

The idea for Luna came out of a personal connection. One of the members of the VRHealth team developed the idea for the technology after undergoing chemotherapy for breast cancer and experiencing hot flashes as a side effect.

Orr said that Luna will officially launch in January of 2019 at CES.

Why it matters

Hot flashes, which are often triggered by a hormone drop, are associated with breast cancer chemotherapy and surgery to remove the ovaries as well as menopause, according to the Cancer Treatment Centers of America (CTCA). While women are most likely to experience hot flashes, the CTCA said that men can also experience the condition.

Common treatment options include hormone therapy, antidepressants and other prescription medications, according to the Mayo Clinic. Alternative medicine including meditation, acupuncture and CBT are also used.

VRHealth is pitching this technology as another avenue to treat the condition, and Orr hinted that in yet-to-be-released clinical trials Luna outperformed medications for hot flash treatment.

What’s the trend

VRHealth was in the news in September when it teamed up with Facebook’s Oculus, which makes VR hardware and other related products, on a range of healthcare-focused VR applications to be delivered on the latter’s hardware.

VR as a whole is growing. Many in healthcare are looking to the technology to help with pain, discomfort and anxiety. Clinicians are deploying it in a wide range of settings including obstetricspediatrics and rehabilitation.

On the record 

“We believe VR can be an amazing replacement for opiates or any kind of nonnatural hormone and the most common treatments that have a lot of side effects,” Orr said. “We believe VR could be a good solution.”

via VRHealth unveils VR software for hot flashes | MobiHealthNews

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[WEB SITE] OCD: Brain mechanism explains symptoms

A large review of existing neuroscientific studies unravels the brain circuits and mechanisms that underpin obsessive-compulsive disorder. The researchers hope that the new findings will make existing therapies more effective, “or guide new treatments.”
doctors looking at brain scans

New research analyzes the brain scans of almost 500 people to unravel the brain mechanisms in OCD.

Obsessive-compulsive disorder (OCD) is a mental health condition that affects more than 2 million adults in the United States.

People with OCD often experience recurring, anxiety-inducing thoughts or urges — known as obsessions — or compulsive behaviors that they cannot control.

Whether it is repeatedly checking if the door is locked or switching lights on and off, OCD symptoms are uncontrollable and can severely interfere with a person’s quality of life.

Treatments for OCD include medication, psychotherapy, and deep brain stimulation. However, not everyone responds to treatment.

In fact, reference studies have found that only 50 percent of people with OCD get better with treatment, and just 10 percent recover fully.

This treatment ineffectiveness is partly down to the fact that medical professionals still do not fully understand the neurological roots of the condition. A new study, however, aims to fill this gap in research.

Scientists led by Luke Norman, Ph.D., a postdoctoral research fellow in the Department of Psychiatry at the University of Michigan (U-M) in Ann Arbor, corroborated and analyzed large amounts of data from existing studies on the neurological underpinnings of OCD.

The scientists published their meta-analysis in the journal Biological Psychiatry.

Studying the brain circuitry in OCD

Norman and colleagues analyzed studies that scanned the brains of hundreds of people with OCD, as well as examining the brain images of people without the condition.

“By combining data from 10 studies, and nearly 500 patients and healthy volunteers, we could see how brain circuits long hypothesized to be crucial to OCD are indeed involved in the disorder,” explains the study’s lead author.

Specifically, the researchers zeroed in on a brain circuit called the “cingulo-opercular network.” This network involves several brain regions that are interconnected by neuronal pathways in the center of the brain.

Studies have previously associated the cingulo-opercular network with “tonic alertness” or “vigilance.” In other words, areas in this brain circuit are “on the lookout” for potential errors and can call off an action to avoid an undesirable outcome.

Most of the functional MRI studies included by Norman and colleagues in their review had volunteers respond to errors while inside the brain scanner.

An analysis of data from the various studies revealed a salient pattern: Compared with people who did not have OCD, those with the condition displayed significantly more activity in brain areas associated with recognizing an error, but less activity in the brain regions that could stop an action.

Study co-author Dr. Kate Fitzgerald of U-M’s Department of Psychiatry explains the findings, saying “We know that [people with OCD] often have insight into their behaviors, and can detect that they’re doing something that doesn’t need to be done.”

She adds, “But these results show that the error signal probably isn’t reaching the brain network that needs to be engaged in order for them to stop doing it.”

The researcher continues using an analogy.

It’s like their foot is on the brake telling them to stop, but the brake isn’t attached to the part of the wheel that can actually stop them.”

Dr. Kate Fitzgerald

“This analysis sets the stage for therapy targets in OCD because it shows that error processing and inhibitory control are both important processes that are altered in people with the condition,” says Fitzgerald.

Findings may boost existing treatments

The researcher also explains how the findings may enhance current treatments for OCD, such as cognitive behavioral therapy (CBT).

“In [CBT] sessions for OCD, we work to help patients identify, confront, and resist their compulsions, to increase communication between the ‘brake’ and the wheels, until the wheels actually stop. But it only works in about half of patients.”

“Through findings like these, we hope we can make CBT more effective, or guide new treatments,” Dr. Fitzgerald adds. The team is currently recruiting participants for a clinical trial of CBT for OCD.

In addition to CBT, Dr. Fitzgerald also hopes that the results will enhance a therapy known as “repetitive transcranial magnetic stimulation” (rTMS).

“If we know how brain regions interact together to start and stop OCD symptoms, then we know where to target rTMS,” she says. “This is not some deep dark problem of behavior,” Dr. Fitzgerald continues.

OCD is a medical problem, and not anyone’s fault. With brain imaging, we can study it just like heart specialists study EKGs of their patients — and we can use that information to improve care and the lives of people with OCD.”

Dr. Kate Fitzgerald

via OCD: Brain mechanism explains symptoms

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[WEB SITE] Is There a Science to Psychotherapy?

Neuroscience findings suggest that psychotherapy alters the brain.

Since the decade of the brain, 1990-1999, neuroscience has captured enormous amounts of attention from both the scientific community and the general public. Many books and media reports describe the brain’s basic anatomy and function. There has been a proliferation of neuroscience institutes at universities. In laboratories all over the world, neuroscience has become one of the most exciting and productive branches of inquiry.

Yet not everyone is completely pleased with what neuroscience has to tell us. In particular, some decry neuroscience for trying to delegitimize the “mind.” Going back to the original Cartesian mind-body duality, these critics insist that neuroscience can only go so far by describing the function of neurons and neurotransmitters. What cannot be reached by science, they say, is that ineffable “mind” that constitutes the human spirit. For them, neuroscience is purely an attempt to reduce the complexities and wonders of human experience to brain scan images and electrical recordings from axons and dendrites.

In a new book, Neuroscience at the Intersection of Mind and Brain (Oxford University Press, 2018), one of us (Jack) attempts to allay fears that neuroscience will somehow reduce human experience and creativity to the “mere” workings of the physical brain. There is, in fact, nothing “reductive” about the physical brain. Rather, the brain is a gloriously complex, fascinating, and well-organized structure that constitutes, as neuroscientist Eric Kandel so eloquently put it, “the organ of the mind.”

Biologists versus Psychologists

As a resident in psychiatry in the late 1970s, Jack witnessed the emergence of psychopharmacology as the dominant discipline for academic psychiatry and lived through the often bitter battles between “biologists” and “psychologists.” This may be, in part, where the mistrust of neuroscience began. The biologists believed that their method of treating psychiatric illness—medication—was based on solid science and rejected psychotherapy as unscientific.  They also believed that neuroscience explained why the new psychiatric drugs worked and therefore promoted brain science as the basis for their discipline. Every lecture about depression or schizophrenia in those days began with a picture of a pre- and postsynaptic neuron forming a synapse across which neurotransmitters like serotonin, noradrenaline, and dopamine carried information. The new medications interact with receptors for these neurotransmitters and, it was taught at the time, this explains how they work to treat depression, anxiety, and psychosis.

 Andrew Rybalko/Shutterstock

Source: Andrew Rybalko/Shutterstock

It turns out that the picture of neurons everyone used back then was a vast oversimplification of what a synapse really looks like and that almost nothing we know about neurotransmitters and their receptors actually explains how psychiatric drugs work. But what really bothered the psychologists was the complete dismissal of psychotherapy by the biologists. Years of studying various types of psychotherapy convinced them that indeed they had science on their side. Furthermore, they objected to the biologists’ emphasis on inherited abnormalities as the sole basis for psychiatric illness. Psychologists had always been more interested in the ways that human experience, from birth onwards, shaped personality and behavior.

Over time, many (but thankfully not all) psychologists came to see neuroscience as the branch of science devoted to promoting pharmacology as the only treatment for psychiatric illness and to trying to prove that those illnesses were entirely due to inherited brain abnormalities. Biologists stood with nature; psychologists with nurture.

This fear of neuroscience’s aims is entirely misplaced. Over the last several decades, neuroscience has, in fact, focused a great deal of attention on the biology of experience, elucidating the ways in which what happens to us in life affects the structure and function of the brain. Every time we see, hear, smell, or touch something, learn a new fact, or have a new experience, genes are activated in the brain, new proteins are synthesized, and neural pathways communicate the new information to multiple brain regions.

Neuroscience is not, therefore, synonymous with psychopharmacology, nor does it invalidate the complexities of human experience. It has shown, for example, that early life interactions between a parent and child shape how the brain will function for the rest of a person’s life.

This has tremendous implications for understanding the mechanism of action of psychotherapy if we accept the idea that psychotherapy itself is a form of life experience and therefore capable of changing brain function at molecular, cellular, and structural levels. Here are two examples that illustrate ways in which neuroscience informs psychotherapy.

CBT and the Prefrontal to Amygdala Connection

It is now clear that the expression of conditioned fear is dependent upon an intact, functioning amygdala. Scientists have shown that the amygdala, located in a primitive part of the brain often referred to as the limbic cortex, reciprocally inhibits and is inhibited by a more evolutionarily advanced part of the brain, the medial prefrontal cortex (mPFC). Thus, under circumstances of heightened fear, the amygdala shuts down the ability of the mPFC to exert reason over emotion and initiates a cascade of fearful responses that include increased heart rate and blood pressure and freezing in place. When the mPFC is able to reassert its capacity for logic and reason, it can, in turn, inhibit the amygdala and reduce and extinguish fear.

Cognitive behavioral therapy (CBT) is an evidence-based intervention that is the first-line treatment for most anxiety disorders and for mild, moderate, and in many cases even severe depression. Because the automatic, irrational fears and avoidance behaviors manifested by patients with anxiety disorders and depression resemble the behavior of rodents in Pavlovian fear conditioning experiments, scientists have wondered if CBT works, at least in part, by strengthening the prefrontal cortex to amygdala pathway, thereby reducing amygdala activity. Indeed, many studies have shown that anxious and depressed patients have reduced activity in this pathway and exaggerated amygdala responses to fearful stimuli. Studies have also shown that successful CBT for social anxiety disorder decreases amygdala activation.

Most recently, a group of scientists from Oxford, Harvard, and Berkeley showed clearly that stimulation of the prefrontal cortex in human volunteers both reduced amygdala activation and fear. Maria Ironside and colleagues selected 18 women with high levels of trait anxiety and randomized them to receive either transcranial direct current stimulation (tDCS) to the prefrontal cortex or sham tDCS. The subjects underwent functional magnetic resonance imaging (fMRI) of the brain and performed an attentional load task that tests vigilance to threat. Real, but not sham, tDCS increased activity in the prefrontal cortex, decreased activity in the amygdala, and decreased threat responses.

This study is one example of preclinical and clinical neuroscience coming together to suggest a biological mechanism for the efficacy of a psychosocial intervention. We know that the cognitive portion of CBT strengthens a patient’s ability to assert reason over irrational thoughts and fears and that this decreases amygdala activity in some studies. We know clearly from animal studies that stimulating the prefrontal cortex reduces amygdala activation and potentiates fear extinction. Now we also know that in a group of anxious people, direct stimulation of the prefrontal cortex does exactly the same thing as it does in animal studies and, in addition, reduces anxiety. With this plausible hypothesis for how CBT works, scientists can now push further to see if brain imaging can ultimately help select patients with particularly weak prefrontal to amygdala pathway strength who might be prime candidates for CBT and then to track how they are doing in therapy objectively by repeating the brain imaging studies to see if and when that pathway is strengthened.

Psychoanalysis and Reconsolidation

CBT has been proven effective by many high-quality clinical trials and therefore is a prime candidate for biological studies, but can the same be said for such widely used but not empirically-validated treatments as psychoanalysis and psychoanalytic psychotherapy? In 2011, Jack and his colleague, Columbia psychiatrist and psychoanalyst Steven Roose, proposed that another aspect of fear conditioning—reconsolidation of fear memories—may explain one biological mechanism of action for how psychoanalysis works. In rats, when a conditioned fear memory is reactivated, it temporarily becomes labile and can be completely erased by blocking the biological mechanisms that permit reconsolidation of the memory. Could it be that in psychoanalytic therapies, the patient undergoes a process of reactivating distressing early memories that, once made conscious through the psychoanalytic process, can be manipulated by the therapist’s interpretations? According to this hypothesis, those now altered memories can then be reconsolidated into permanent memory in a less disturbing format.

The theory has been considered since then by many scientists and psychoanalytic theorists and a number of experiments show that the phenomena of labile reactivated memories and blockade of reconsolidation do indeed occur in humans. Blocking reconsolidation of reactivated memories has been shown to be effective in experiments attempting to help addicts overcome the powerful tendency to succumb to subtle cues and resume taking drugs even after successful rehabilitation. Here again, information gained from the basic neuroscience laboratory and from clinical neuroscience studies may help us understand how one aspect of psychoanalysis works to change the brain in ways that are helpful to people suffering with mental illness.

It is not necessary to invoke an ineffable “mind” to explain our unique human characteristics. Understanding the complexity of the human brain is sufficient to reveal how we are able to take what we experience and transform it into scientific theories, poetry, and philosophical ideas. Neuroscience is not superficial or reductionistic and it is not at all in the sole service of psychopharmacology and the genetic explanation for mental disorders. This becomes clear as we recognize the tremendous contributions neuroscientists have made to elucidating basic mechanisms that allow experiences to change the physical structure and function of the brain on a second-by-second basis. Everything we experience during life is translated into events that occur in the brain.

Psychotherapy is a form of life experience that changes the way the brain works, often ameliorating abnormalities caused by adverse experience and stressful life events. So yes, there is a science to psychotherapy, one that can be readily understood by learning about some of the fundamental and fascinating ways our brains work. Neuroscience at the Intersection of Mind and Brain tries to do just that.

via Is There a Science to Psychotherapy? | Psychology Today UK

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[WEB SITE] OCD: Cognitive behavioral therapy improves brain connectivity

MRI scans show that people diagnosed with OCD who have undergone CBT have intensified connectivity between key brain networks.

Researchers have used brain scans to measure changes in the cerebral activity of people with obsessive-compulsive disorder after undergoing a type of cognitive behavioral therapy. They found that the connectivity of key brain networks is improved, suggesting new targets for therapy.

Obsessive-compulsive disorder (OCD) is a condition marked by inescapable, intrusive thoughts that cause anxiety (hence “obsessive”), and repetitive, ritualistic behaviors aimed at reducing that feeling (hence “compulsive”).

OCD can be a debilitating condition and can severely impair daily functioning. The National Institutes of Mental Health estimate that, in the United States, the yearly prevalence of OCD amounts to 1 percent of the total adult population. Around half of these cases are deemed “severe.”

Treatments for OCD include the administration of selective serotonin reuptake inhibitors and cognitive behavioral therapy (CBT), a type of therapy that aims to improve damaging mind associations.

Researchers from the University of California, Los Angeles – who were led by Dr. Jamie Feusner – have conducted a study aiming to find out whether and how CBT might change levels of activity and network connectivity in the brains of people diagnosed with OCD.

They explain that although the efficacy of CBT in treating OCD has been previously explored, this is likely the first study to use functional MRI (fMRI) to monitor what actually happens in the brains of people with OCD after exposure to this kind of therapy.

The researchers’ findings were recently published in the journal Translational Psychiatry.

Changes in key brain regions following CBT

The team specifically targeted the effects of exposure and response prevention (ERP)-based CBT, which entails exposure to triggering stimuli and encouraging the individual to wilfully resist responding to those stimuli in the way that they normally would.

For the study, 43 people with OCD and 24 people without it were recruited. The results for the two groups were later compared, at which point the 24 individuals without OCD were taken as the control group.

All the participants diagnosed with OCD received intensive ERP-based CBT on an individual basis in 90-minute sessions on 5 days per week, for a total of 4 weeks.

Participants from both groups underwent fMRI. Those diagnosed with OCD, who had received CBT, were scanned both before the treatment period and after the 4 weeks of treatment. Participants from the control group, who did not undergo CBT, also had fMRI scans after 4 weeks.

When the scans of participants with OCD were compared, the results from before exposure to CBT and after it were found to be largely contrasting.

The researchers noticed that the brains of people with OCD exhibited a significant increase in connectivity between eight different brain networks, including the cerebellum, the caudate nucleus and putamen, and the dorsolateral and ventrolateral prefrontal cortices.

 The cerebellum is involved with processing information and determining voluntary movements, while the caudate nucleus and putamen are key in learning processes and controlling involuntary impulses.

The dorsolateral and ventrolateral prefrontal cortices are involved with planning action and movement, as well as regulating certain cognitive processes.

Dr. Feusner and team point out that an increased level of connectivity between these cerebral regions suggests that the brains of the people who underwent CBT were “learning” new non-compulsive behaviors and activating different thought patterns.

He suggests that these changes may be novel ways of coping with the cognitive and behavioral idiosyncrasies of OCD.

The changes appeared to compensate for, rather than correct, underlying brain dysfunction. The findings open the door for future research, new treatment targets, and new approaches.”

Dr. Jamie Feusner

First study author Dr. Teena Moody adds that being able to show that there are quantifiable positive changes in the brain following CBT may give people diagnosed with OCD more confidence in following suitable treatments.

“The results could give hope and encouragement to OCD patients,” says Dr. Moody, “showing them that CBT results in measurable changes in the brain that correlate with reduced symptoms.”

Source: OCD: Cognitive behavioral therapy improves brain connectivity

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