Treatments (1)

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Oct 30, 2023

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Treatments -Psychotherapy -Mindfulness -Collaborative Therapeutic Neuropsychological Assessment

The one that you might be most familiar with…. Psychotherapy Psychotherapy is an intensely personal dialogue between two individuals that results in a working (or therapeutic) relationship in which one person (the therapist) attempts to help another (the patient or client) cope with a personal problem or problems the latter individual seems to have difficulty managing on his or her own. Therapist Musts: 1. Therapist = professional training in understanding the nature of the patient’s personal struggles as well as his or her neuropsychological strengths and limitations (know their role) 2. The therapist must have the capacity to form a therapeutic relationship and skill at guiding this learning process. (have ability to execute their role) 3. Finally, the therapist must have the time and willingness to help the patient. (be available for their role) Client Musts: 1. The patient (or client) needs the financial resources to pay for this service (pay) 2. Have adequate cognitive and emotional/motivational skills to learn from the dialogue, and the willingness to “face the truths” in his or her life. (be able and willing) https://www.youtube.com/watch?v=ZdyOwZ4_RnI https://www.youtube.com/watch?v=ltNhwj-F7c8

Several Types Psychotherapy Cognitive Behavioural Therapy : A type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behavior patterns or treat mood disorders such as depression • Viewed as highly effective and used in clinic frequently Psychodynamic psychotherapy or psychoanalytic psychotherapy: is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension Goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something), but also foster the positive presence of psychological capacities and resources • Misconception that it is not well scientifically studied • Shedler (2010) : meta-analyses reveal that the overall effect sizes of psychotherapy for treating depression can be substantial (size effect of 0.73, mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was 0.31 ) It is normal that patients may report increased irritability, anxiety, and depression as they attempt to cope with their cognitive limitations

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Your Role Psychotherapy and the NP Psychotherapy should be attempted by the clinical neuropsychologist , who understands the patient’s brain- behavior difficulties and has a willingness and professional training to help the patient improve his/her/their psychological adjustment to the effects of the brain disorder We will Discuss Three Case Studies where the NP + Psychotherapy can be useful: 1. Depression and Psychotherapy After Cerebral Vascular Accident (or Stroke) 2. Multiple Sclerosis, Anxiety, and Depression 3. Denial/Unawareness of Impaired Neuropsychological Functioning after Severe Traumatic Brain Injury

Clinically defined depression is common after stroke -estimates of major depressive disorder are in the range of 20%, while estimates of minor depression range from 9% to 18%. Depression after Stroke Severely depressed 33 year old woman - three years post a ruptured arteriouvenous malformation (AVM) involving the right parietal lobe, currently working as a statistician in a hospital She had been a physician in a residency program in radiology, after surgical resection of her AVM and apparent neurological recovery she had returned to her program but she was not knowledgeable/did not understand why she had difficulty perceiving different “shadows” on the imaging films and consequently left her residency program because she could not meet academic requirements She was asked to keep a journal and encouraged to express herself in it: -her dreams and poetry revealed all of the frustrations and psychodynamics of not living up to one’s personal aspirations in life -through psychotherapy she was probed about her medical aspirations -Should you leave the game (i.e., the aspiration to be a radiologist) or be a doctor in a substantially reduced capacity) since you love the “game” so much Conclusion: She chose to work for an insurance company conducting histories and physicals. She enjoyed patient care (it gave her a sense of meaning in life) and as a consequence her depression slowly resolved into predictable human sadness over a major loss in life. Her neuropsychological rehabilitation was successful in large part due to the impact of psychotherapy.

MS is a common neurological disorder that results in demyelination of axons and the formulation of sclerotic plagues - which may manifest as neurocognitive deficits For MS specifically - they specially noted that the variable and unpredictable nature of symptoms could certainly increase the psychological distress level of patients. -Feinstein (2011) suggests that significant depression can affect up to 50% of patients with MS and anxiety is also very common in depressed MS patients Multiple Sclerosis, Anxiety, and Depression 50-year-old male who had been diagnosed as having MS for at least ten years. He was now complaining of memory difficulties. At that time, many neurologists did not believe that MS patients should have memory difficulties, but the NP at the time tested and illustrated that this patient did indeed have memory deficits. This caused the patient to seek out the NP to help with his his depression and anger over having MS . He told NP general facts about his childhood and why he choose to be an engineer. With time he also spoke about how he often was uncomfortable with women, but eventually married his wife of some 30 years. In conjoint sessions with his wife, she talked about her husband getting very angry, very quickly over what appeared to be slight frustrations in life. After several other individual sessions with this patient, he asked the NP to pull out the Rorschach cards and specially show him Card VIII (a card he had previously avoided). He then gave me his perceptions of what the card looked like to him and stated that when he looked at this card he was reminded of his mother. As an adolescent boy his mother would approach him in a negligee and ask him to rub her back. He was both sexually excited and scared by these repeated experiences. This always occurred when his father was not home. He did not want to be alone with his mother (and now knew why he probably was uncomfortable as a man when being alone with women). This is a prime example frequently observed in psychodynamic psychotherapy. The goal is not to simply focus on the past, but to understand how the past sheds light on current psychological difficulties With the help of psychotherapy, he began to be less angry and less frightened about his disease. He accepted his wife’s help with his physical limitations and could also accept he could no longer function as an engineer in light of his memory difficulties. He experienced a certain internal peace of mind and his anger was substantially reduced.

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A key issue when providing psychotherapy for patients with moderate or severe TBI who show poor self-awareness of their residual neuropsychological disturbances, is obtaining a realistic understanding of what is causing their apparent lack of awareness Denial/Unawareness of Impaired Neuropsychological Functioning after Severe Traumatic Brain Injury Young man who had a moderate TBI and who refused to admit to any substantial cognitive difficulties. He was frequently belligerent and argued that whatever difficulties he had performing neuropsychological tests were irrelevant or existed prior to his injury. Helping him face his tendency for risk taking and propensity to engage in addictive behaviors slowly resulted in his acknowledging that his memory was indeed compromised. After several years of psychotherapy, he began to make more adaptive choices regarding work and interpersonal relationships. These types of patients are perhaps the most difficult to treat, but helping them understand the psychological basis of their denial is crucial for a successful outcome. Working closely with a psychiatrist who can provide psychotropic mediations as needed is also very important when working with these individuals. Table 46.1 Suggestions for conducting psychotherapy after brain injury when there has been signifi cant disruption of higher integrative brain functions and patient requires a holistic, milieu-oriented neuropsychological rehabilitation program (adapted from Prigatano et al., 1986) 1 Provide a model or models that help the patient understand what has happened to him or her. 2 Help the patient deal with the meaning of the brain injury in his or her life. 3 Help the patient achieve a sense of self-acceptance and forgiveness for himself or herself and others who may have caused the accident. 4 Help the patient make realistic commitments to work and interpersonal relations. 5 Teach the patient how to behave in di ff erent social situations (to improve competence). 6 Provide specific behavioral strategies for compensating for neuropsychological deficits. 7 Foster a sense of realistic hope.

mindfulness- based interventions (MBIs) have the potential to positively impact multiple aspects of emotional, behavioral, biological, and neuropsychological functioning in ways that may be of benefit to individuals with different diagnoses Mindfulness Mindfulness has three essential qualities: Agreed Upon Working definition by Agency for Healthcare Research and Quality (a) a defined technique allowing for a describable set of instructions for practice; (b) an element described as “logic relaxation,” meaning that there is a lack of intent to make judgments, create expectations, or analyze the practice itself (c) a self-induced state or mode, indicating that a person is not under the direct instruction of another person (i.e., as in hypnosis) -> modified to allow for: -meditation during which one remains stationary (i.e., transcendental meditation or other sitting practices) -meditation that involve awareness during meditative movement (i.e., yoga, Tai Chi). Jon Kabat-Zinn (1994), the founder of the Mindfulness-Based Stress Reduction (MBSR) program: “Mindfulness means paying attention in a particular way: on purpose, in the present moment, and non- judgmentally.”

MBSR Over time, MBSR has evolved into the current design, in which the intervention is administered as an eight-week group program. Individuals in the program are required to participate in group education and practice for two-hour sessions weekly, and are asked to engage in individual practice at home on a daily basis. Initial components = body awareness: practiced through sitting and supine mindfulness meditation practices involving focusing on the breath, and engaging in the “Body Scan,” which entails bringing awareness to successive body areas in a sequential manner with the aim of focused attention and awareness of sensations occurring with each body area. Progressing: sessions include didactic presentations, movement (mindful Hatha yoga and mindful walking), as well as specific exercises in mindful eating and observation of positive and negative thoughts. An all-day silent retreat is part of the program as well. It should be noted that, from its inception, while MBSR practices are derived from Eastern traditions of meditation and yoga, Kabat-Zinn intentionally removed specific cultural or philosophical language from the program in a concerted effort to make it universally accessible to clinical patients of all background

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Effectiveness? Study 1: Kabat-Zinn and colleagues (1985) used a ten-week course of mindfulness meditation to train 90 individuals with chronic pain, com- pared to a group of pain patients receiving traditional treatment protocols. Measures evaluating self-report of present-moment pain, negative body image, inhibition of activity due to pain, symptoms, mood disturbance and psychological symptoms, including those related to anxiety and depression symptoms were measured. The utilization of pain medications, activity levels and self-esteem reports were also monitored over the course of treatment. Results indicated statistically significant positive changes in all measures, including physical and emotional symptoms and pain-related behaviors when pre- and posttreatment assessments were compared. In addition, utilization of pain-related medications was significantly decreased. Results indicated that findings of improvement appeared to be independent of gender, referral source, and type of pain. Study 2: Baer, Carmody, and Hunsinger (2012) evaluated the weekly changes in self-reported mindfulness and perceived stress in a group of 87 adults with chronic illness, pain, and life stressors who were engaged in an MBSR program Via evaluation of weekly questionnaires, significant increases in the acquisition of mindfulness skills, as well as significantly decreased reports of perceived stress were reported from pretreatment to posttreatment overall

Something is happening in your brain Its a replicated finding Meditation Neuroimaging studies of Buddhist monks and other master practitioners of meditation have shown significantly altered brain structure and function. For example, in a structural neuroimaging study of 22 long-term meditators as compared to 22 nonexperienced control participants using voxel-based morphometry, Luders and colleagues (2009) found gray matter volumes to be significantly larger in the right orbito- frontal cortex and the right hippocampus for meditators as compared to controls. ... And This Is Your Brain On Buddha: As part of his research, Andrew Newberg studied the brain activity of experienced Tibetan Buddhists before and during meditation. Newberg found an increase of activity in the meditators' frontal lobe, responsible for focusing attention and concentration, during meditation.

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https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5540331/ Kirtan Kriya Memory Study Step 1: Mild Cognitive Impairment Condition: Recruited older individuals with memory problems Patients Screened: No history of prior meditation Step 2: Taught them Kirtan Kriya meditation -SA, TA, NA, M -Finger movements (mudras) Step 3: Scanned their brain before and after 8 weeks of training Step 4: Tested their memory https://www.youtube.com/watch?v=jfKEAiwrgeY

https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5540331/ Kirtan Kriya: NP Tests NP testing revealed a significant improvement in scores on a verbal fluency test with naming animals • concentration were also substantially improved • Increase of activation in specific brain areas • Anterior cingulate gyrus (1.21±0.11 after vs 1.03±0.20 before) • Right prefrontal cortex (1.13±0.14 after vs 0.97±0.10 before) • Right globus pallidus (1.12±0.13 after vs 1.04±0.12 before) • Midbrain.(0.93±0.07 after vs 0.85±0.05 before).

Several studies support these findings In TBI TBI: Bédard and colleagues (2003) 12 weekly sessions, which included a form of mindfulness-based meditation called Insight Meditation, breathing exercises, guided visualization, and group discussion focusing on altering perceptions of disability, increasing acceptance, and moving beyond limiting beliefs. Subjects were ten individuals with mild to moderate TBI who were at least one year postinjury. Findings of this pilot indicated improvements in self- reports of quality of life and on the cognitive-affective domains. The authors concluded that the intervention was simple and had improved quality of life after other treatment options were exhausted.

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Needs More Scientific Study After Stroke Lawrence and colleagues (2013) conducted a review of four studies of the use of MBIs with individuals with a history of stroke. In total, 160 participants were involved across the four studies. Three interventions were delivered via a group format and one was delivered one-to-one. The authors report a positive trend in findings, suggesting benefits ranging across multiple psychological and physiological outcomes, including depression, fatigue, blood pressure, perceived health, anxiety, and quality of life.

Collaborative Therapeutic Neuropsychological Assessment (CTNA) is a method for giving feedback from neuropsychological test results that is based on client-centered principles Collaborative Therapeutic Neuropsychological Assessment: Using your tools as therapy CTNA begins with seven basic assumptions: 1 The patient/caregiver/referral source has noticed a change in the patient’s cognitive and/or behavioral functioning and would like a professional to determine if there is a true change. 2 The patient/family members are distressed because of a change in the patient’s cognitive/behavioral functioning. 3 Patients would like to learn potential ameliorative strategies so that they are able to perform better in school, work, and social spheres. 4 Patients want to be respected and empowered as active and autonomous participants in treatment and decision making. 5 Neuropsychological tests provide objective, concrete information about patients’ cognitive and behavioral functioning as it applies to their daily life and problems they may be experiencing. 6 Feedback from neuropsychological tests can help answer questions regarding changes in cognitive and behavioral functioning, provide hypotheses as to causes of change, and give direction for treatment. 7 Feedback presented in a patient-centered manner can enlist the patient as an active collaborator, empower the individual in the treatment and decision making process, and lower resistance to hearing difficult or discrepant information. This will motivate the patient to work more closely with professionals to alleviate his or her problems and distress.

CASE 1: TBI ❖ Male bicyclist, late 40s struck by an automobile while cycling ❖ Glasgow Coma Score of 8, right frontal, subdural, subarachnoid, and intraparenchymal hemorrhaging with seizure activity ❖ seven months postinjury: struggle with nausea, occasional dizziness, cognitively difficulty sustaining attention, overwhelmed with large amounts of stimulation, anxious to get back to his normal activities, particularly exercising. ❖ NP TESTS: ❖ patient had average = intellectual functioning, tests of attention, working memory, visuomotor tracking, verbal learning and immediate recall, retention, and recognition, visual recognition, expressive language, and response inhibition. ❖ moderate deficits = psychomotor speed, cognitive flexibility ❖ mild deficits in verbal encoding and delayed verbal memory, higher level executive functions, mildly impaired processing speed ❖ significant visuoconstructional deficits

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Interaction with Therapist Through Diagnosis Procedure and Interviewing Interaction brings to light two issues: 1. Struggled with multitasking 2. larger issue = patient’s frustration and impatience with his perceived lack of progress and intense desire to “get better” and get back to normal activities. gorske : “Do you remember the test that required you to draw a line connecting numbers and letters? Like 1-A, 2-B, etc.?” patient : “Oh yes, I remember that. I think I started o ff OK but then I got lost?” gorske : “That’s right, you started o ff pretty well but then lost track about half way through. Do you remember what it was like to do that test?” patient : “I’m not entirely sure. I think I remember just saying it in my head (1-A, 2-B, 3-C) but then at some point I kind of blanked and forgot what I was doing. I’m not sure I can explain it any better.” (The patient’s wife is sitting behind him and nodding vigorously). gorske : “So it seems like when it comes to activities where you have to move your attention from one thing to another as quick as you can, you might do OK for a while but then find yourself lost. It looks like you wife has something to add to this.” patient ’ s wife : “Yes, this is what happens throughout the day. He tries very hard to help out around the house, which is fine if I give him one thing to do and he sticks with it, but then he tries to do more than one thing at a time; he starts out OK but then there are times I’ll see him just standing there looking lost.” gorske : (To patient) “Did what she said make sense and have you noticed this yourself?” patient : “I don’t really notice when I blank out until some- one sort of wakes me up . Then I realize that I haven’t done what I set out to do. It’s frustrating because I’m really trying to get better. It’s been what, eight months now? I feel like I should be back to normal now and that’s what gets me more depressed than anything. I’m not depressed like sleeping all day or want to kill myself, I just get impatient and down.” patient ’ s wife : “Honestly, you're trying too hard I think.”

Applying CTNA ❖ This case illustrates some of the ways CTNA can be used in neurological disorder cases: ❖ 1 Awareness and insight: In this patient’s case, there was evidence of anosognosia that was keeping him from being fully aware of his cognitive and functional deficits. However, there was also an element of emotional denial given his premorbid personality was one of very high activity that was almost obsessive in nature yet functional. Now that same pre- morbid tendency was a detriment to recovery because the patient became overwhelmed easily and his insistence on pushing through actually caused him to regress. The objective data, combined with an empathic and inquisitive approach presented in small and understandable points, allowed the patient to gradually integrate the information and, with the help of his spouse, use the information to enhance his recovery. ❖ 2 Providing information about cognition that is applicable and relevant: In order to make the cognitive information understandable and relevant, a continual give and take occurred between the neuropsychologist, patient, and family member about what skills the tests are assessing and how those skills apply to the patients’ daily life. One method for this is using plain and simple language. A second method is find- ing an example in the patient’s daily life that he or she can relate to and use that situation to illustrate a cognitive skill. ❖ 3 Developing recovery plans: From one test (Trail Making B) two important recovery issues were identified, including (a) the need to break up multitasking activities into smaller parts, and (b) the need to increase rest breaks and learn to listen to his mind and body to avoid exhausting himself and compromising his health and recovery.

CASE 2: Glioblastoma (Recovery not possible) ❖ Marisa was born in 1976 to a Sicilian father and a mother from the island of Malta. Marisa was described as a very intelligent, passionate, and strong-willed young woman who had an intense zest for life and was not afraid to express her opinions to others. She was especially passionate about good food and restaurants in Pittsburgh, Pennsylvania, and had high standards as to how food should be cooked, served, and savored. She earned a Master’s Degree in Social Work in 2001 and was working with children in the Pittsburgh public schools. ❖ First symptom April 26, 2006 (seizure), May 23, 2006 (Cancer Diagnosis), NP meeting July 15, 2006 ❖ The predominant theme that arose from the meetings and feedback session was Marisa’s strong and intense desire to hold onto her sense of self, which she felt was being robbed of by the tumor and consequent treatments. ❖ This was a case study that is a love letter about patient resilience and worth a read….

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You are an NP have a variety of tools of treatment available to you, and which one you choose and why, and for which patient will significantly shape your practise.

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