Tag Archives: Cognitive behavioral therapy

Cognitive Behavioural Therapy (CBT)

Definition:
Cognitive behavior therapy (CBT) is a type of psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders including phobias, addictions, depression, and anxiety.

CLICK & SEE

Cognitive behavioral therapy (CBT) is a short-term psychotherapy originally designed to treat depression, but is now used for a number of mental illnesses. It works to solve current problems and change unhelpful thinking and behavior.  The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles.  Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought, but rather emerge based on prior conditioning from the environment and other external and/or internal stimuli. CBT is “problem focused” (undertaken for specific problems) and “action oriented” (therapist tries to assist the client in selecting specific strategies to help address those problems),  or directive in its therapeutic approach.

CBT has been demonstrated to be effective for the treatment of a variety of conditions, including mood, anxiety, personality, eating, substance abuse, tic, and psychotic disorders. Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments.  However, other researchers have questioned the validity of such claims to superiority over other treatments.

Description:
Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in affect and behavior,[8] but recent variants emphasize changes in one’s relationship to maladaptive thinking rather than changes in thinking itself.  Therapists or computer-based programs use CBT techniques to help individuals challenge their patterns and beliefs and replace “errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing” with “more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior.”  These errors in thinking are known as cognitive distortions. Cognitive distortions can be either a pseudo- discrimination belief or an over-generalization of something.  CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward them so as to diminish their impact. Mainstream CBT helps individuals replace “maladaptive… coping skills, cognitions, emotions and behaviors with more adaptive ones”,  by challenging an individual’s way of thinking and the way that they react to certain habits or behaviors,  but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.

Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.  Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.

CBT has six phases:
1.Assessment or psychological assessment;
2.Reconceptualization;
3.Skills acquisition;
4.Skills consolidation and application training;
5.Generalization and maintenance;
6.Post-treatment assessment follow-up.

The reconceptualization phase makes up much of the “cognitive” portion of CBT.   A summary of modern CBT approaches is given by Hofmann.

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them.  Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”. Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Types of Cognitive Behavior Therapy:
There are a number of different approaches to CBT that are regularly used by mental health professionals. These types include:
•Rational Emotive Behavior Therapy (REBT)
•Cognitive Therapy
•Multimodal Therapy

Medical uses of CBT:
In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders,  depressioneating disorders chronic low back painpersonality disorderspsychosis,  schizophrenia,  substance use disorders,  in the adjustment, depression, and anxiety associated with fibromyalgia,  and with post-spinal cord injuries.  Evidence has shown CBT is effective in helping treat schizophrenia, and it is now offered in most treatment guidelines.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders,  body dysmorphic disorder,  depression and suicidality,  eating disorders and obesity,  obsessive–compulsive disorder,  and posttraumatic stress disorder,  as well as tic disorders, trichotillomania, and other repetitive behavior disorders.

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition.   Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,  nor was it helpful in treating men who abuse their intimate partners.

According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either “proven” or “presumed” to be an effective therapy on several specific mental disorders.  According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.  However, psychodynamic therapy may provide better long-term outcomes.

Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children,  as well as insomnia.  Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.  CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety  and insomnia.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners.  However evidence supports the effectiveness of CBT for anxiety and depression.

Mounting evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioral problems.  A systematic review of CBT in depression and anxiety disorders concluded that “CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists.”

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD);  hypochondriasis;  coping with the impact of multiple sclerosis;  sleep disturbances related to aging; dysmenorrhea;  and bipolar disorder,  but more study is needed and results should be interpreted with caution. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter,  but not in reducing stuttering frequency.

Martinez-Devesa et al. (2010) found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Turner et al. (2007) found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,[39] and Smedslund et al. (2007) found that it was not helpful in treating men who abuse their intimate partners.

In the case of metastatic breast cancer, Edwards et al. (2008) maintained that the current body of evidence is not sufficient to rule out the possibility that psychological interventions may cause harm to women with this advanced neoplasm.

In adults, CBT has been shown to have a role in the treatment plans for anxiety disorders; depression;  eating disorders;  chronic low back pain;  personality disorders;  psychosis; schizophrenia;  substance use disorders;  in the adjustment, depression, and anxiety associated with fibromyalgia;  and with post-spinal cord injuries.  There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.  CBT has been shown to be moderately effective for treating chronic fatigue syndrome.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders;  body dysmorphic disorder;  depression and suicidality;  eating disorders and obesity;  obsessive–compulsive disorder;  and posttraumatic stress disorder;  as well as tic disorders, trichotillomania, and other repetitive behavior disorders. CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youth who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. Sparx is a video game to help young persons, using the CBT method to teach them how to resolve their own issues. That’s a new way of therapy, which is quite effective for child and teenager. CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age).  Cognitive Behavior Therapy has also been applied to a variety of childhood disorders,  including depressive disorders and various anxiety disorders.

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive–compulsive disorder (OCD), bulimia nervosa, and clinical depression

Use of CBT  in other different ways:
With older adults:
CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age.   Some of the challenges to CBT because of age include the following:
The Cohort effect The times that each generation lives through partially shape its thought processes as well as values, so a 70-year-old may react to the therapy very differently from a 30-year-old, because of the different culture in which they were brought up. A tie-in to this effect is that each generation has to interact with one another, and the differing values clashing with one another may make the therapy more difficult.  Established role By the time one reaches old age, the person has a definitive idea of her or his role in life and is invested in that role. This social role can dominate who the person thinks he or she is and may make it difficult to adapt to the changes required in CBT. Mentality toward aging If the older individual sees aging itself as a negative this can exacerbate whatever malady the therapy is trying to help (depression and anxiety for example).  Negative stereotypes and prejudice against the elderly cause depression as the stereotypes become self-relevant.[88]Processing speed decreasesAs we age, we take longer to learn new information, and as a result may take more time to learn and retain the cognitive therapy. Therefore, therapists should slow down the pacing of the therapy and use any tools both written and verbal that will improve the retention of the cognitive behavioral therapy.

Prevention of mental illness:
For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes.  In another study, 3% of the group receiving the CBT intervention developed generalized anxiety disorder by 12 months post intervention compared with 14% in the control group.  Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT.  Use of CBT was found to significantly reduce social anxiety prevalence.

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older.  Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles.[99] A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.

For schizophrenia, one study of preventative CBT showed a positive effect   and another showed neutral effect.

Criticisms of Cognitive Behavior Therapy:
The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments,[148] many other researchers  and practitioners  have questioned the validity of such claims. For example, one study  determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority.

Furthermore, other researchers  write that CBT studies have high drop-out rates compared to other treatments. At times, the CBT drop-out rates can be more than five times higher than other treatments groups. For example, the researchers provided statistics of 28 participants in a group receiving CBT therapy dropping out, compared to 5 participants in a group receiving problem-solving therapy dropping out, or 11 participants in a group receiving psychodynamic therapy dropping out.

Other researchers  conducting an analysis of treatments for youth who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youth who self-injure. The researchers concluded that none of them were found to be efficacious. These conclusions  were made using the APA Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures to determine intervention potency.

However, the research methods employed in CBT research have not been the only criticisms identified. Others have called CBT theory and therapy into question. For example, Fancher  writes the CBT has failed to provide a framework for clear and correct thinking. He states that it is strange for CBT theorists to develop a framework for determining distorted thinking without ever developing a framework for “cognitive clarity” or what would count as “healthy, normal thinking.” Additionally, he writes that irrational thinking cannot be a source of mental and emotional distress when there is no evidence of rational thinking causing psychological well-being. Or, that social psychology has proven the normal cognitive processes of the average person to be irrational, even those who are psychologically well. Fancher also says that the theory of CBT is inconsistent with basic principles and research of rationality, and even ignores many rules of logic. He argues that CBT makes something of thinking that is far less exciting and true than thinking probably is. Among his other arguments are the maintaining of the status quo promoted in CBT, the self-deception encouraged within clients and patients engaged in CBT, how poorly the research is conducted, and some of its basic tenets and norms: “The basic norm of cognitive therapy is this: except for how the patient thinks, everything is ok”.

Meanwhile, Slife and Williams  write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT invokes a type of cause-and-effect relationship with cognition. They state that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states. Nowhere in CBT theory is agency, or free will, accounted for. At its most basic foundational assumptions, CBT holds that human beings have no free will and are just determined by the cognitive processes invoked by external stimuli.

Another criticism of CBT theory, especially as applied to Major Depressive Disorder (MDD), is that it confounds the symptoms of the disorder with its causes.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in.[156] Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.

Resources:
http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
http://psychology.about.com/od/psychotherapy/a/cbt.htm

Advertisements

BALANCE DISORDER

Definition:
A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness or wooziness, or having a sensation of movement, spinning, or floating. Balance is the result of several body systems working together: the visual system (eyes), vestibular system (ears) and proprioception (the body’s sense of where it is in space). Degeneration or loss of function in any of these systems can lead to balance deficits
CLICK  & SEE THE PICTURES
Balance disorders can be caused by certain health conditions, medications, or a problem in the inner ear or the brain.

Our sense of balance is primarily controlled by a maze-like structure in our inner ear called the labyrinth, which is made of bone and soft tissue. At one end of the labyrinth is an intricate system of loops and pouches called the semicircular canals and the otolithic organs, which help us maintain our balance. At the other end is a snail-shaped organ called the cochlea, which enables us to hear. The medical term for all of the parts of the inner ear involved with balance is the vestibular system.

Symptoms:
When balance is impaired, an individual has difficulty maintaining upright orientation. For example, an individual may not be able to walk without staggering, or may not even be able to stand. They may have falls or near-falls. The symptoms may be recurring or relatively constant. When symptoms exist, they may include:

*Dizziness or vertigo (a spinning sensation)
*Falling or feeling as if you are going to fall
*Lightheadedness, faintness, or a floating sensation
*Blurred vision
*Confusion or disorientation

Some individuals may also experience nausea and vomiting, diarrhea, faintness, changes in heart rate and blood pressure, fear, anxiety, or panic. Some reactions to the symptoms are fatigue, depression, and decreased concentration. The symptoms may appear and disappear over short time periods or may last for a longer period.

Cognitive dysfunction (disorientation) may occur with vestibular disorders. Cognitive deficits are not just spatial in nature, but also include non-spatial functions such as object recognition memory. Vestibular dysfunction has been shown to adversely affect processes of attention and increased demands of attention can worsen the postural sway associated with vestibular disorders. Recent MRI studies also show that humans with bilateral vestibular damage undergo atrophy of the hippocampus which correlates with their degree of impairment on spatial memory tasks

Causes:
Problems with balance can occur when there is a disruption in any of the vestibular, visual, or proprioceptive systems. Abnormalities in balance function may indicate a wide range of pathologies from causes like inner ear disorders, low blood pressure, brain tumors, and brain injury including stroke.

Many different terms are often used for dizziness, including lightheaded, floating, woozy, giddy, confused, helpless, or fuzzy. Vertigo, Disequilibrium and pre-syncope are the terms in use by most physicians and have more precise definitions.

*Vertigo: Vertigo is the sensation of spinning or having the room spin about you. Most people find vertigo very disturbing and report associated nausea and vomiting.

*Disequilibrium: Disequilibrium is the sensation of being off balance, and is most often characterized by frequent falls in a specific direction. This condition is not often associated with nausea or vomiting.

*Pre-syncope (links to syncope, which is different): Pre-syncope is a feeling of lightheadedness or simply feeling faint. Syncope, by contrast, is actually fainting. A circulatory system deficiency, such as low blood pressure, can contribute to a feeling of dizziness when one suddenly stands up.

Problems in the skeletal or visual systems, such as arthritis or eye muscle imbalance, may also cause balance problems.

Related to the ear:
Causes of dizziness related to the ear are often characterized by vertigo (spinning) and nausea. Nystagmus (flickering of the eye, related to the Vestibulo-ocular reflex [VOR]) is often seen in patients with an acute peripheral cause of dizziness.

*Benign Paroxysmal Positional Vertigo (BPPV) – The most common cause of vertigo. It is typically described as a brief, intense sensation of spinning that occurs when there are changes in the position of the head with respect to gravity. An individual may experience BPPV when rolling over to the left or right, upon getting out of bed in the morning, or when looking up for an object on a high shelf.  The cause of BPPV is the presence of normal but misplaced calcium crystals called otoconia, which are normally found in the utricle and saccule (the otolith organs) and are used to sense movement. If they fall from the utricle and become loose in the semicircular canals, they can distort the sense of movement and cause a mismatch between actual head movement and the information sent to the brain by the inner ear, causing a spinning sensation.

*Labyrinthitis – An inner ear infection or inflammation causing both dizziness (vertigo) and hearing loss.

*Vestibular neuronitis – an infection of the vestibular nerve, generally viral, causing vertigo

*Cochlear Neuronitis – an infection of the Cochlear nerve, generally viral, causing sudden deafness but no vertigo.

 

*Trauma – Injury to the skull may cause either a fracture or a concussion to the organ of balance. In either case an acute head injury will often result in dizziness and a sudden loss of vestibular function.

*Surgical trauma to the lateral semicircular canal (LSC) is a rare complication which does not always result in cochlear damage. Vestibular symptoms are pronounced. Dizziness and instability usually persist for several months and sometimes for a year or more.

   *Ménière’s disease – an inner ear fluid balance disorder that causes lasting episodes of vertigo, fluctuating hearing loss, tinnitus (a ringing or roaring in the ears), and the sensation of fullness in the ear. The cause of Ménière’s disease is unknown.

    *Perilymph fistula a leakage of inner ear fluid from the inner ear. It can occur after head injury, surgery, physical exertion or without a known cause.

    *Superior canal dehiscence syndrome – a balance and hearing disorder caused by a gap in the temporal bone, leading to the dysfunction of the superior canal.

  *Bilateral vestibulopathy – a condition involving loss of inner ear balance function in both ears. This may be caused by certain antibiotics, anti-cancer, and other drugs or by chemicals such as solvents, heavy metals, etc., which are ototoxic; or by diseases such as syphilis or autoimmune disease; or other causes. In addition, the function of the semicircular canal can be temporarily affected by a number of medications or combinations of medications.

 

Related to the brain and central nervous system:
Brain related causes are less commonly associated with isolated vertigo and nystagmus but can still produce signs and symptoms, which mimic peripheral causes. Disequilibrium is often a prominent feature.

*Degenerative: age related decline in balance function
*Infectious: meningitis, encephalitis, epidural abscess, syphilis
*Circulatory: cerebral or cerebellar ischemia or hypoperfusion, stroke, lateral medullary syndrome (Wallenberg’s syndrome)
*Autoimmune: Cogan syndrome
*Structural: Arnold-Chiari malformation, hydrocephalus
*Systemic: multiple sclerosis, Parkinson’s disease
*Vitamin deficiency: Vitamin B12 deficiency
*CNS or posterior neoplasms, benign or malignant
*Neurological: Vertiginous epilepsy
*Other – There are a host of other causes of dizziness not related to the ear.

*Mal de debarquement is rare disorder of imbalance caused by being on board a ship. Patients suffering from this condition experience disequilibrium          even when they get off the ship. Typically treatments for seasickness are ineffective for this syndrome.

*Motion sickness – a conflict between the input from the various systems involved in balance causes an unpleasant sensation. For this reason, looking          out of the window of a moving car is much more pleasant than looking inside the vehicle.

*Migraine-associated vertigo
*Toxins, drugs, medications

Pathophysiology:
The semicircular canals, found within the vestibular apparatus, let us know when we are in a rotary (circular) motion. The semicircular canals are fluid-filled. Motion of the fluid tells us if we are moving. The vestibule is the region of the inner ear where the semicircular canals converge, close to the cochlea (the hearing organ). The vestibular system works with the visual system to keep objects in focus when the head is moving. This is called the vestibulo-ocular reflex (VOR).
Click & see :
Movement of fluid in the semicircular canals signals the brain about the direction and speed of rotation of the head – for example, whether we are nodding our head up and down or looking from right to left. Each semicircular canal has a bulbed end, or enlarged portion, that contains hair cells. Rotation of the head causes a flow of fluid, which in turn causes displacement of the top portion of the hair cells that are embedded in the jelly-like cupula. Two other organs that are part of the vestibular system are the utricle and saccule. These are called the otolithic organs and are responsible for detecting linear acceleration, or movement in a straight line. The hair cells of the otolithic organs are blanketed with a jelly-like layer studded with tiny calcium stones called otoconia. When the head is tilted or the body position is changed with respect to gravity, the displacement of the stones causes the hair cells to bend.

click & see
The balance system works with the visual and skeletal systems (the muscles and joints and their sensors) to maintain orientation or balance. For example, visual signals are sent to the brain about the body’s position in relation to its surroundings. These signals are processed by the brain, and compared to information from the vestibular, visual and the skeletal systems.
Diagnosis:
Diagnosis of a balance disorder is complicated because there are many kinds of balance disorders and because other medical conditions — including ear infections, blood pressure changes, and some vision problems — and some medications may contribute to a balance disorder. A person experiencing dizziness should see a physiotherapist or physician for an evaluation. A physician can assess for a medical disorder, such as a stroke or infection, if indicated. A physiotherapist can assess balance or a dizziness disorder and provide specific treatment.

The primary physician may request the opinion of an otolaryngologist to help evaluate a balance problem. An otolaryngologist is a physician/surgeon who specializes in diseases and disorders of the ear, nose, throat, head, and neck, sometimes with expertise in balance disorders. He or she will usually obtain a detailed medical history and perform a physical examination to start to sort out possible causes of the balance disorder. The physician may require tests and make additional referrals to assess the cause and extent of the disruption of balance. The kinds of tests needed will vary based on the patient’s symptoms and health status. Because there are so many variables, not all patients will require every test.

Diagnostic testing:
Tests of vestibular system (balance) function include electronystagmography (ENG), Videonystagmograph (VNG), rotation tests, Computerized Dynamic Posturography (CDP), and Caloric reflex test.

Tests of auditory system (hearing) function include pure-tone audiometry, speech audiometry, acoustic-reflex, electrocochleography (ECoG), otoacoustic emissions (OAE), and auditory brainstem response test (ABR; also known as BER, BSER, or BAER).

Other diagnostic tests include magnetic resonance imaging (MRI) and computerized axial tomography (CAT, or CT).

Treatment and Prevention:
There are various options for treating balance disorders. One option includes treatment for a disease or disorder that may be contributing to the balance problem, such as ear infection, stroke, multiple sclerosis, spinal cord injury, Parkinson’s, neuromuscular conditions, acquired brain injury, cerebellar dysfunctions and/or ataxia. Individual treatment will vary and will be based upon assessment results including symptoms, medical history, general health, and the results of medical tests. Additionally, tai chi may be a cost-effective method to prevent falls in the elderly.

Many types of balance disorders will require balance training, prescribed by an occupational therapist or physiotherapist. Physiotherapists often administer standardized outcome measures as part of their assessment in order to gain useful information and data about a patient’s current status. Some standardized balance assessments or outcome measures include but are not limited to the Functional Reach Test, Clinical Test for Sensory Integration in Balance (CTSIB), Berg Balance Scale and/or Timed Up and Go The data and information collected can further help the physiotherapist develop an intervention program that is specific to the individual assessed. Intervention programs may include training activities that can be used to improve static and dynamic postural control, body alignment, weight distribution, ambulation, fall prevention and sensory function. Although treatment programs exist which seek to aid the brain in adapting to vestibular injuries, it is important to note that it is simply that – an adaptation to the injury. Although the patient’s balance is restored, the balance system injury still exists

Benign Paroxysmal Positional Vertigo (BPPV):
It is caused by misplaced crystals within the ear. Treatment, simply put, involves moving these crystals out of areas that cause vertigo and into areas where they do not. A number of exercises have been developed to shift these crystals. The following article explains with diagrams how these exercises can be performed at the office or at home with some help: The success of these exercises depends on their being performed correctly.

The two exercises explained in the above article are:

*The Brandt-Daroff Exercises, which can be done at home and have a very high success rate but are unpleasant and time consuming to perform.

*The Epley’s exercises are often performed by a doctor or other trained professionals and should not be performed at home. Various devices are available      for home BPPV treatment.

Ménière’s disease:
  *Diet:
Dietary changes such as reducing intake of sodium (salt) may help. For some people, reducing alcohol, caffeine, and/or avoiding nicotine may be               helpful. Stress has also been shown to make the symptoms associated with Ménière’s worse.

 *Drugs:
#Beta-histine (Serc) is available in some countries and is thought to reduce the frequency of symptoms
#Diuretics such as hydrochlorothiazide (Diazide) have also been shown to reduce the frequency of symptoms
#Aminoglycoside antibiotics (gentamicin) can be used to treat Ménière’s disease. Systemic streptomycin (given by injection) and topical gentamicin         (given directly to the inner ear) are useful for their ability to affect the hair cells of the balance system. Gentamicin also can affect the hair  cells of the cochlea, though, and cause hearing loss in about 10% of patients. In cases that do not respond to medical management, surgery may be indicated.

      *Surgery for Ménière’s disease is a last resort.
#Vestibular neuronectomy can cure Ménière’s disease but is very involved surgery and not widely available. It involves drilling into the skull and  cutting the balance nerve just as it is about to enter the brain.
#Labyrinthectomy (surgical removal of the whole balance organ) is more widely available as a treatment but causes total deafness in the affected ear.

Labyrinthitis:
Treatment includes balance retraining exercises (vestibular rehabilitation). The exercises include movements of the head and body specifically developed for the patient. This form of therapy is thought to promote habituation, adaptation of the vestibulo-ocular reflex, and/or sensory substitution. Vestibular retraining programs are administered by professionals with knowledge and understanding of the vestibular system and its relationship with other systems in the body.

Bilateral vestibular loss:
Dysequilibrium arising from bilateral loss of vestibular function – such as can occur from ototoxic drugs such as gentamicin – can also be treated with balance retraining exercises (vestibular rehabilitation) although the improvement is not likely to be full recovery

Medication:
Sedative drugs are often prescribed for vertigo and dizziness, but these usually treat the symptoms rather than the underlying cause. Lorazepam (Ativan) is often used and is a sedative which has no effect on the disease process rather helps patients cope with the sensation.

Anti-nauseants, like those prescribed for motion sickness, are also often prescribed but do not affect the prognosis of the disorder.

Specifically for Meniere’s disease a medication called Serc (Beta-histine) is available. There is some evidence to support it is effective to reduce the frequency of attacks. Also Diuretics, like Diazide (HCTZ/triamterene), are effective in many patients. Finally, ototoxic medications delivered either systemically or through the eardrum can eliminate the vertigo associated with Meniere’s in many cases, although there is about a 10% risk of further hearing loss when using ototoxic medications.

Treatment is specific for underlying disorder of balance disorder:

#anticholinergics
#antihistamines
#benzodiazepines
#calcium channel antagonists, specifically Verapamil and Nimodipine
#GABA modulators, specifically gabapentin and baclofen
#Neurotransmitter reuptake inhibitors such as SSRI’s, SNRI’s and Tricyclics

Research:
Scientists at the National Institute on Deafness and Other Communication Disorders (NIDCD) are working to understand the various balance disorders and the complex interactions between the labyrinth, other balance-sensing organs, and the brain. NIDCD scientists are studying eye movement to understand the changes that occur in aging, disease, and injury, as well as collecting data about eye movement and posture to improve diagnosis and treatment of balance disorders. They are also studying the effectiveness of certain exercises as a treatment option.

Other projects supported by the NIDCD include studies of the genes essential to normal development and function in the vestibular system. NIDCD scientists are also studying inherited syndromes of the brain that affect balance and coordination.

The NIDCD supports research to develop new tests and refine current tests of balance and vestibular function. For example, NIDCD scientists have developed computer-controlled systems to measure eye movement and body position by stimulating specific parts of the vestibular and nervous systems. Other tests to determine disability, as well as new physical rehabilitation strategies, are under investigation in clinical and research settings.

Scientists at the NIDCD hope that new data will help to develop strategies to prevent injury from falls, a common occurrence among people with balance disorders, particularly as they grow older.
Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://en.wikipedia.org/wiki/Balance_disorder
http://www.medicinenet.com/vestibular_balance_disorders/article.htm#what_is_a_balance_disorder

Electro-Convulsive Therapy

Definition:
Electroconvulsive therapy (ECT) is a procedure in which electric currents are passed through the brain, deliberately triggering a brief seizure. Electroconvulsive therapy seems to cause changes in brain chemistry that can immediately reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.

click to see

Electroconvulsive therapy (ECT), formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Its mode of action is unknown. Today, ECT is most often recommended for use as a treatment for severe depression which has not responded to other treatment, and is also used in the treatment of mania and catatonia. It was first introduced in the 1938 and gained widespread use as a form of treatment in the 1940s and 1950s.

click to see

Informed consent is a standard of modern electroconvulsive therapy. According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically only used in cases of great extremity, and only when all other treatment options have been exhausted and the use of ECT is believed to be a potentially life saving treatment. However, caution must be exercised in interpreting this assertion as, in an American context, there does not appear to have been any attempt to survey at national level the usage of ECT as either an elective or involuntary procedure in almost twenty years. In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent

click to see

Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and positive outcomes. After treatment, drug therapy is usually continued, and some patients receive continuation/maintenance ECT. In the United Kingdom and Ireland, drug therapy is continued during ECT.

click to see

The treatment involves placing electrodes on the temples, on one or both sides of the patient’s head, and delivering a small electrical current across the brain, with the patient sedated or under anaesthetic. The aim is to produce a seizure lasting up to a minute, after which the brain activity should return to normal. Patients may have one or more treatment a week, and perhaps more than a dozen treatments in total.

Although ECT has been used since the 1930s, there is still no generally accepted theory to explain how it works. One of the most popular ideas is that it causes an alteration in how the brain responds to chemical signals or neurotransmitters.

Why & when it is done?
Electroconvulsive therapy (ECT) can provide rapid, significant improvements in severe symptoms of a number of mental health conditions. It may be an effective treatment in someone who is suicidal, for instance, or end an episode of severe mania.

ECT is used to treat:
*Severe depression, particularly when accompanied by detachment from reality (psychosis), a desire to commit suicide or refusal to eat.

*Treatment-resistant depression, long-term depression that doesn’t improve with medications or other treatments.

*Schizophrenia, particularly when accompanied by psychosis, a desire to commit suicide or hurt someone else, or refusal to eat.

*Severe mania, a state of intense euphoria, agitation or hyperactivity that occurs as part of bipolar disorder. Other signs of mania include impaired decision making, impulsive or risky behavior, substance abuse and psychosis.

click to see

*Catatonia, characterized by lack of movement, fast or strange movements, lack of speech, and other symptoms. It’s associated with schizophrenia and some other psychiatric disorders. In some cases, catatonia is caused by a medical illness.

Electroconvulsive therapy is sometimes used as a last-resort treatment for:

#Treatment-resistant obsessive compulsive disorder, severe obsessive compulsive disorder that doesn’t improve with medications or other treatments

#Parkinson’s disease, epilepsy, and certain other conditions that cause movement problems or seizures

*Tourette syndrome that doesn’t improve with medications or other treatments

ECT may be a good treatment option when medications aren’t tolerated or other forms of therapy haven’t worked. In some cases ECT is used:

#During pregnancy, when medications can’t be taken because they might harm the developing fetus

#In older adults who can’t tolerate drug side effects

#In people who prefer ECT treatments over taking medications

#When ECT has been successful in the past

Risk factor:
Patients are given short-acting anaesthetics, muscle relaxants and breathe pure oxygen during the short procedure in order to minimise the risks. However, although ECT is much safer than it was, there are still side effects to the treatment. The most common are headache, stiffness, confusion and temporary memory loss on awaking from the treatment – some of these can be reduced by placing electrodes only on one side of the head. Memory loss can be permanent in a few cases, and the spasms associated with the seizure can cause fractured vertebrae and tooth damage. However, the recommended use of muscle relaxant nowadays makes the latter a very rare occurrence. Patients can also experience numbness in the fingers and toes.

The death rate from ECT used to be quoted as one for every 1,000 patients, but with smaller amounts of electric current used in modern treatments, accompanied by more safety techniques, this has been reduced to as little as four or five in 100,000 patients.

Recomendations:
A common argument against ECT is that it destroys brain cells, with experiments conducted on animals in the 1940s often cited as evidence. However, modern studies have yet to reproduce these findings in the human brain.

Some activists, however, still campaign against the widespread use of ECT in psychiatry, quoting those cases which have resulted in long-term damage or even death, whether because of the built-in chance of problems, or through errors by doctors.

Experts say that given the correct staff training, and when used for the right clinical conditions, ECT can ‘dramatically’ benefit the patient. An audit of ECT in Scotland between February 1996 and August 1999 said concerns about unacceptable side effects, effectiveness of the treatment and disproportionate use on elderly people were ‘largely without foundation’.

It said that in nearly three quarters of cases people with depressive illness showed ‘a definite improvement’ after ECT. Women were more likely to receive the treatment than men, but the auditors said this was because they were twice as likely to suffer from depression. Only 12 per cent of patients who got ECT were aged over 75. However, the Royal College of Psychiatrists has admitted that in the past the treatment has been administered by untrained, unsupervised junior doctors. However, modern guidelines have changed this and ECTAS (ECT Accreditation Services) exist to check that such treatment is being given safely and efficiently.

Guidelines on ECT from NICE (2003) recommend that it’s used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment. options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:

•Severe depressive illness
•Catatonia
•Prolonged or severe manic episode

NICE also says that ‘valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. The decision to use ECT should be made jointly by the individual and the clinician(s) responsible for treatment, on the basis of an informed discussion. This discussion should be enabled by the provision of full and appropriate information about the general risks associated with ECT and about the risks and potential benefits specific to that individual. Consent should be obtained without pressure or coercion, which may occur as a result of the circumstances and clinical setting, and the individual should be reminded of their right to withdraw consent at any point. There should be strict adherence to recognised guidelines about consent and the involvement of patient advocates and/or carers to facilitate informed discussion is strongly encouraged.’

 

Click to learn more  in detail  about  Electro-Convulsive Therapy

You may click to see:-

Keep fighting even when depression treatments don’t work
Video:Electroconvulsive therapy

DSM-IV Codes
Harold A. Sackeim
Insulin shock therapy
History of electroconvulsive therapy in the United Kingdom
Psychiatric survivors movement
Consumer/Survivor/Ex-Patient Movement
List of people who have undergone electroconvulsive therapy

 

Resources:
http://www.mayoclinic.com/health/electroconvulsive-therapy/MY00129
http://www.bbc.co.uk/health/physical_health/conditions/electro_convulsive_therapy.shtml
http://en.wikipedia.org/wiki/Electroconvulsive_therapy

http://www.minddisorders.com/Del-Fi/Electroconvulsive-therapy.html

Enhanced by Zemanta

Meditation Key to Treat Depression


People with severe and recurrent depression could benefit from a new form of therapy that combines ancient forms of meditation with modern   cognitive behaviour therapy, early-stage research by Oxford University psychologists suggests.

.CLICK  & SEE

The results of a small-scale randomised trial of the approach, called mindfulness-based cognitive therapy (MBCT), in currently depressed patients are published in the journal Behaviour Research and Therapy.

In an experiment, 28 people currently suffering from depression, having also had previous episodes of depression and thoughts of suicide, were randomly assigned into two groups.

One group received MBCT in addition to treatment as usual, while the other just received treatment as usual. The result indicated that the number of patients with major depression reduced in the group which received treatment with MBCT while it remained the same in the other group.

The therapy included special classes of meditation learning and advice on how best participants can look after themselves when their feelings threaten to overwhelm them.

Professor Mark Williams, who along with his colleagues in the Department of Psychiatry at the University of Oxford, developed the treatment said, “We are on the brink of discovering really important things about how people can learn to stay well after depression.”

Sources: The Times Of India

 

‘Talking Cure’ for Mental Problems

Intensive psychoanalytic therapy, the “talking cure” rooted in the ideas of Freud, has all but disappeared in the age of drug treatments and managed care.
But now researchers are reporting that the therapy can be effective against some chronic mental problems, including anxiety and borderline personality disorder.

In a review of 23 studies of such treatment involving 1,053 patients, the researchers concluded that the therapy, given as often as three times a week, in many cases for more than a year, relieved symptoms of those problems significantly more than did some shorter-term therapies.

CLICK & SEE

The authors, writing in Wednesday’s issue of the Journal of the American Medical Association, strongly urged scientists to undertake more testing of psychodynamic therapy, as it is known, before it is lost altogether as a historical curiosity. The review is the first such evaluation of psychoanalysis to appear in a major medical journal, and the studies on which the new paper was based are not widely known among doctors.

The field has resisted scientific scrutiny for years, arguing that the process of treatment is highly individualized and so does not easily lend itself to such study. It is based on Freud’s idea that symptoms are rooted in underlying, often longstanding psychological conflicts that can be discovered in part through close examination of the patient-therapist relationship.

Experts cautioned that the evidence cited in the new research was still too meager to claim clear superiority for psychoanalytic therapy over different treatments, like cognitive behavior therapy, a shorter-term approach. The studies that the authors reviewed are simply not strong enough, these experts said.

“But this review certainly does seem to contradict the notion that cognitive or other short-term therapies are better than any others,” said Bruce Wampold, chairman of the department of counseling psychology at the University of Wisconsin.

“When it’s done well, psychodynamic therapy appears to be just as effective as any other for some patients, and this strikes me as a turning point” for such intensive therapy.

The researchers, Falk Leichsenring of the University of Giessen and Sven Rabung of the University Medical Center Hamburg-Eppendorf, both in Germany, reviewed only those studies in which the therapy had been frequent – more than once a week – and had lasted at least a year or, alternatively, had been 50 sessions long. Further, the studies had to have followed patients closely, using strict definitions of improvement.

The investigators examined studies that tracked patients with a variety of mental problems, among them severe depression, anorexia nervosa and borderline personality disorder, which is characterized by a fear of abandonment and dark squalls of despair and neediness.

Psychodynamic therapy, Leichsenring wrote in an email message, “showed significant, large and stable treatment effects which even significantly increased between the end of treatment and follow-up assessment”.

The review found no correlation between patients’ improvement and the length of treatment. But improve they did, and psychiatrists said it was clear that patients with severe, chronic emotional problems benefited from the steady, frequent, close attention that psychoanalysts provide.

The new review is encouraging, some psychoanalysts said, but also a reminder of how much more study needs to be done.

Sources: The Times Of India

Enhanced by Zemanta