Therapy of Social Anxiety Disorder (5)

Therapy-of-Social-Anxiety-Disorder-5-Christian-Jonathan-Haverkampf-psychotherapy-series

Therapy of Social Anxiety Disorder

Christian Jonathan Haverkampf, M.D.

Social anxiety disorder can significantly reduce an individual’s choices in life and the quality of life overall. Since communication is the process by which humans fulfil their needs, values and aspirations, its effectiveness is important for satisfaction, contentment and happiness in life. It is the main autoregulatory instruments, also in the psychotherapeutic process, to promote mental health. If interpersonal communication is interfered with by anxiety, these processes can no longer work effectively. As the individual withdraws further, the capabilities for needs fulfilment and autoregulation decline further.

Focusing on interpersonal and intrapersonal communication patterns can help to reverse the vicious cycle of social anxiety. Communication-Focused Therapy® (CFT®) provides a toolset, methodological and theoretical framework to facilitate the awareness for individual communication patterns and the interventions to improve them in line with the patient’s needs, values and aspirations.

Keywords: social anxiety, communication-focused therapy, CFT, CBT, psychodynamic psychotherapy, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Self-Image. 4

External Image. 5

Focus. 5

Experiencing the Interaction. 6

Transparency. 6

Habituation. 7

Social Network. 7

Social Exclusion. 7

Hierarchies. 8

Technology. 8

Symptoms. 9

Measurement 9

Neurobiology. 9

The Amygdala. 9

Identity. 10

‘Lost Opportunities’ 11

Judgment 11

Location. 11

Treatment 12

Cognitive-Behavioral Therapy (CBT) 12

Psychodynamic Psychotherapy. 13

Mindfulness-based stress reduction (MBSR) 13

D-Cycloserine. 13

Communication-Focused Therapy® (CFT®) 13

Introduction. 14

Communication as Autoregulation. 14

Communication Patterns. 14

Attention. 15

Communication to Participate in Life. 15

Understanding Social Anxiety and Shyness. 15

Internal Communication. 16

Uncertainty. 16

Communication Deficits. 16

Avoidance. 17

Meaning. 17

Awareness of Thought Patterns. 17

Flow of Information. 18

Emotional Reconnection. 18

Experiencing the World. 18

Communication Techniques. 19

Breaking the Cycle of Anxiety. 19

The Reward of Seeing More. 20

Values, Needs and Aspirations. 20

The Need for Communication. 20

Meaningful Messages as the Instrument of Change. 21

Embracing Change. 22

Living. 23

References. 24

Introduction

A person suffering from social anxiety disorder feels unwell in social situations and begins to avoid them, which can not infrequently lead to significant problems in daily life. Social anxiety is more than just shyness. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. (World Health Organization, 1992) The prevalence of 12-month and lifetime prevalence of social anxiety disorder is around 3% and 5%, respectively. (Grant et al., 2005) It is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. (Stein & Stein, 2008) In a study by La Greca and Lopez on adolescents, girls reported more social anxiety than boys, and social anxiety was more strongly linked to girls’ social functioning than to that of boys. Girls with higher levels of social anxiety reported fewer friendships, and less intimacy, companionship, and support in their close friendships. (La Greca & Lopez, 1998)   Social anxiety disorder is also sometimes referred to as social phobia.

Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (e.g., personality trait neuroticism) core phenotypes to identify risk loci. (Stein & Stein, 2008) There are several psychological and psychopharmacological treatments (Haverkampf, 2017h) available. Communication-Focused Therapy® (CFT®) as developed by the author is an approach that targets the processes and patterns which are underlying interpersonal interactions. (Haverkampf, 2013, 2017a, 2018f)

Self-Image

The sense of a stable self-image plays an important role in lowering social anxiety. The more confident one is oneself, and thus the more one is connected with oneself in a meaningful way, the lower the anxiety will be in interpersonal or social situations. Having a good and stable self-image requires connection with oneself, the ability to be open and receptive to information that originates within oneself, other than the information that is received from the external world through the sense, for example. Even though the distinction between the internal and the external maybe somewhat artificial, it is important to acknowledge that there are sources of information which are not in the external world. In some psychiatric conditions, such as in psychosis, this distinction between the external and the internal can get lost with potentially severe consequences.

How the internal self-image can affect the communication with others has been demonstrated by Hirsch and colleagues. One group was asked to hold in mind a negative self‐image, while the other held in mind a less negative (control) self‐image. When holding the negative image, the socially anxious volunteers felt more anxious, reported using more safety behaviors, believed that they performed more poorly, and showed greater overestimation of how poorly they came across (relative to ratings by the conversational partner). Conversational partners rated the socially anxious volunteers’ performance as poorer in the negative image condition. Furthermore, both groups of participants rated its quality as poorer in the negative image condition. (Hirsch et al., 2004)

External Image

Social anxiety arises when individuals are motivated to make a preferred impression on real or imagined audiences, such as when one tries to portray an image to others one believes others want to see, or where a person believes there is an external benefit to making oneself appear with certain characteristics. This is inextricably linked to the fear that just being oneself is not good enough, that one will be judged in unpredictable and possibly harsh ways by everyone or a defined group of others.

The cognitive state of the individual can mediate both affective arousal and behavior. (Schlenker & Leary, 1982) At the same time, external factors within the environment can have an effect on how an individual thinks and feels in a given situation, which is also influenced by individual predispositions and traits. In clinical experience, the more an individual tries to adhere to portraying an external image that is believed to be required by external factors and other people, but which does not match with the individual’s communication styles and personality traits, needs, values and aspirations, the less stable the interaction will become, leading to more anxiety and a mutually less satisfying experience. (Haverkampf, 2010a, 2013)

Focus

When it comes to the important role of information dynamics in the epigenesis of social anxiety, focus is an important mediator because it selects the information that becomes available in an interaction. Since all forms of anxiety arise from a deficit of meaningful information or unhelpful ways of processing it, social anxiety can be improved by helping a patient to learn more helpful ways in selecting and focusing on particular types of information.

Socially anxious individuals are excessively concerned about negative evaluation by others. And they often focus more on threat cues or imagined threat cues. In a study by Mansell and colleagues, high socially anxious individuals when compared to low socially anxious individuals showed an attentional bias away from emotional (positive and negative) faces when under conditions of social-evaluative threat. (Mansell et al., 1999) As discussed above, this leads to a situation where less information is available to the socially anxious person, which does not help mitigate the social anxiety.

Socially-anxious individuals also have an increased number of negative cognitions and fewer positive cognitions, while situational factors appear to mediate the absolute level of reactivity. (Beidel et al., 1985) This probably turns the focus even more away from sources of information which could lead to a reduction in the anxiety, resulting in a vicious cycle in which social withdrawal and more negative interpretation of interpersonal interactions and the environment overall leads to even more social withdrawal. In Communication-Focused Therapy® this cycle can be broken by working on the communication patterns the individual uses, which are the structural entities that facilitate the information flow to him or her.

Experiencing the Interaction

Many people who are suffering from social anxiety are familiar with the feeling of continuously asking themselves what other people are thinking about them. In one study, anxious subjects were more likely to attribute more meaning to others’ thoughts. (Hezel & McNally, 2014) The same study interestingly also found that socially anxious individuals performed worse on theory of mind tasks. Theory of mind is the ability to attribute mental states — beliefs, intents, desires, emotions, knowledge, etc. — to oneself and to others. It is necessary to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own. In other words, to fully appreciate the separate mind of another person with its unique content and information processing requires a theory of mind, which seems impaired in individuals with social anxiety. However, to fully reflect on the information dynamics and communication patterns within an interaction it is important to have a basic working concept of an “I” and a “You”. Communication-Focused Therapy® also includes techniques aimed at strengthening this distinctions. (Haverkampf, 2017a, 2017e)

A person suffering from social anxiety takes great pains to not only try to follow the dynamics of an interaction but at the same time to interpret what the partners to an interaction are thinking and feeling about them. While individuals with social anxiety are often quite perceptive and sensitive to various channels of information, this can lead to an information overload, which as a result makes them turn away from the interaction, which increases the anxiety even to a higher level. Communication-Focused Therapy® attempts to reverse this vicious cycle by developing awareness for communication patterns and information flows and practicing communication in a way that leads to fulfilment of own needs, values and aspirations, which also lowers the anxiety.

Transparency

Being able to give oneself permission to practice greater openness in communicating with others is an important step towards overcoming social anxiety. The feedback and information from others help to lower the anxiety as others’ dreaded thoughts turn out to be untrue. However, many people suffering from social anxiety already believe that they are overly transparent to others, that others can see what they are thinking and feeling, such as the anxiety or negative feelings, such as anger or frustration, which could interfere with the social bond from the interaction. As the distinction between the inside and outside worlds of the mind are weaker, the socially anxious person tries even harder to control themselves. Individuals with social anxiety are often quite sensitive, but their interpretation of information is often more on the negative side. Depression with anxiety can mask as the ‘pure’ social anxiety disorder.

Interesting is that studies suggest that socially anxious individuals remember more negative memories than those less distressed. This may either have a biological explanation or be a learned phenomenon. However, since social anxieties do seem to run in families at least partially, there may be a biological explanation to it.  A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Habituation

Habituation is the process by which through a ‘getting used’ to an anxiety or fear inducing stimulus the psychological and physical reaction to it decreases. One becomes less anxious or fearful in the face of information that otherwise induced anxiety or fear, such as the visual input that one is looking out high up on a tall building, if one exposes oneself repeatedly to the information. Social anxiety involves social cues that can induce anxiety. The latency at which habituation occurs, however, seems to be different in individuals that are suffering from social anxiety. (Beidel et al., 1985)

From the perspective of Communication-Focused Therapy® (CFT), any information that is repetitive and has lost its characteristics of novelty will lead to a lesser response, whether in terms of feelings, emotions, thoughts or otherwise. Thus, the internal and external context matters whether habituation will take place. One may reach habituation in one type of situation and when experiencing a particular family of thoughts and perceptions, but conventional behavioural and cognitive methods in the form of CBT, for example, often lead to improvements that are limited in time and circumstance. However, changing one’s exposure to meaningful information, that is information which brings about a change in the recipient, through changes in communication patterns, can be highly effective. Changes in communication patterns also have a longer-lasting effect because the flow of information is permanently altered. CFT works to adjust the communication patterns in the session through awareness, reflection, experimentation and change. It is not primarily the change in perspective or learning new thought patterns that bring about change but changes in communication patterns that determine them through the information they make available, and how information is processed. (Haverkampf, 2010b, 2017a) Practising new communication patterns in the therapeutic session usually shows a significant over time with respect to anxiety, but also anxiety in general.

Social Network

Various aspects of social relations uniquely contribute to feelings of internal distress. In a study by La Greca and Harrison with adolescents, crowd affiliations (high and low status), positive qualities in best friendships, and the presence of a dating relationship protected adolescents against feelings of social anxiety, whereas relational victimization and negative interactions in best friendships predicted high social anxiety. In contrast, affiliation with a high-status peer crowd afforded some protection against depressive affect; however, relational victimization and negative qualities of best friendships and romantic relationships predicted depressive symptoms. (La Greca & Harrison, 2005)

Social Exclusion

Baumeister and Tice’s social exclusion theory of anxiety proposes that a primary source of anxiety is perceived exclusion from important social groups. The relationship between perceived social exclusion and social anxiety, jealousy, loneliness, and depression. Self-esteem can moderate reactions to perceived exclusion. (Leary, 1990) Relationships are expectations of future communication (Haverkampf, 2018c), and not being part of a web of communication increases anxiety. One of the reasons is that living organisms fulfil their needs, and in the case of humans also their values and aspirations, through communication, the exchange of meaningful information with others (Haverkampf, 2010a). Not just the shared reality, but even only the imagined reality can lead to significant anxiety.

Hierarchies

Social rank theory (Price and Sloman, 1987; Gilbert, 1989, 1992) argues that emotions and moods are significantly influenced by the perceptions of one’s social status or rank; that is the degree to which one feels inferior to others and looked down on. A common outcome of such perceptions is submissive behavior. Gilbert showed in a study that shame, social anxiety and depression (but not guilt) are highly related to feeling inferior and to submissive behavior. (Gilbert, 2000) Since these feelings develop from the workings of communication patterns as they determine the information that will ultimately reach various centers of the brain (Haverkampf, 2018c), an adjustment to these communication patterns changes feelings that can be associated with social anxiety. Especially with feelings that have a strong social context, such as shame, changes in communication patterns with the help of a therapeutic seeting can be very helpful. Shame is a result of internal and external communication patterns that are being used, while communication patterns can be influenced by a feeling of shame. Important is to remember that work with any communication pattern can be used to change the whole vicious cycle. (Haverkampf, 2017d, 2017a)

Technology

Increasing the number of available communication channels, such as adding communication via the Internet, can in theory help reduce the sense of isolation rather than increasing it. However, this has been hotly discussed. A study by Caplan supports the hypothesis that the relationship between loneliness and preference for online social interaction is spurious, and that social anxiety is the confounding variable. (Caplan, 2007) Communication means offered by the Internet are tools to interact with humans or human-designed programs in a meaningful way. It depends on what the individual makes out of them. How much one can use a technology to one’s advantage depends on the use of the right communication patterns and an insight into the own basic parameters, including one’s needs, values and aspirations. (Haverkampf, 2017f)

A ‘reduced channel’ communication offered, for example, by online chats or social networks may make it easier for a person suffering from social anxiety to connect with others, but to do in a less anxiety provoking and non-threatening way. As long as it is seen as steps on the way towards overcoming the social anxiety and adding more channels of communication, according to the individual needs, preferences and aspirations, it can be even helpful. For many people suffering from social anxiety the step from no communication to full interpersonal interaction in subjectively experienced high stakes settings can be too high. Online dating platforms, for example, can make it possible for people to go on dates who would otherwise never been able to do so.

Symptoms

Social anxiety often leads to physical symptoms that can worsen the vicious cycle of trying not to appear nervous and anxious, but by ‘fighting’ to do so the nervousness and anxiety just keep on getting worse. In adults, feelings of social anxiety may be associated with tears, blushing, excessive sweating, nausea, difficulty breathing, shaking, and palpitations. They are somatic manifestations, though often experienced much more intensely subjectively than observed objectively, of the fight-or-flight-response, which is largely hardwired into our brains. Since as we have discussed previously, social success is as much a matter of survival as finding food or warding off an attacker, anything that seems to interfere with it can lead to negative emotional states, such as anxiety.

Research suggests that socially anxious individuals interpret ambiguous social information in a more threatening manner compared to non-anxious individuals. It has even been shown that experimentally modifying interpretation in non-anxious individuals affected their anxiety. (Beard & Amir, 2008) Since how information is interpreted depends on external communication channels and on how the information is communicated internally, the techniques of Communication-Focused Therapy work with communication patterns to affect a change. As external and internal communication patterns reflect each other (Haverkampf, 2010a, 2010b, 2017a), the work on communication patterns in therapy has a direct effect on the internal information processing that leads to and maintains social anxiety.

Measurement

The clinically most commonly used questionnaire to assess social anxiety is the Liebowitz Social Anxiety Scale (LSAS). The LSAS has been empirically shown to be a reliable, valid and treatment sensitive measure of social phobia. (Heimberg et al., 1999) It lists a variety of different situations and asks to rate for anxiety and avoidance. This practical orientation is very helpful because it leads to greater insight into the underlying motives of the anxiety. For example, if the contexts of the anxiety provoking situations have in common that they are more of an interpersonal nature with people that are familiar (or strangers), awareness of it can lead to greater understanding of possible underlying causes. People adapt particular communication patterns as a reaction to the perceived need to manage interpersonal dynamics.

Neurobiology

The Amygdala

The amygdala is often implicated in social anxiety and the processing of social threats. In a quantitative meta-analysis, Etkin and Wager compared functional magnetic resonance imaging and positron emission tomography studies of posttraumatic stress disorder (PTSD), social anxiety disorder, specific phobia, and fear conditioning in healthy individuals. Patients with any of the three disorders consistently showed greater activity than matched comparison subjects in the amygdala and insula, structures linked to negative emotional responses. Hyperactivation in the amygdala and insula were, of interest, more frequently observed in social anxiety disorder and specific phobia than in PTSD. Only patients with PTSD, on the other hand, showed hypoactivation in the dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex—structures linked to the experience and regulation of emotion. (Etkin & Wager, 2007)

Amygdala activation to interpersonal threat has been linked to the severity of social anxiety symptoms. Phan and colleagues examined in a study the association between response to emotionally harsh faces in the amygdala and severity of social anxiety symptoms in patients with generalized social phobia. Relative to happy faces, activation of the amygdala in response to harsh (angry, disgusted, fearful) faces was greater in the patients than in controls, and the extent of amygdala activation was positively correlated with severity of social anxiety symptoms, but not general state or trait anxiety levels. (Phan et al., 2006)

However, it needs to be remembered in this context that information is stored in many areas of the brain which all contribute to the signals that then flow through and are integrated, compared, subtracted and processed in specific areas like the amygdala. (Haverkampf, 2018g) Thus, to understand the complexity, and at the same time simplicity of social anxiety one also needs to look at the actual communication patterns an individual uses, externally and internally, and how information is received, selected for, transported and stored. Meaning

Identity

An important question is why I as a socially anxious person feel as the center of attention if it is not what I want, or is it? Many people with social anxieties actually want to have good relationships and are often fond of people. The problem is how they see themselves or that in many cases they cannot really see who they are. Sometimes there may also be an ambivalence in one’s relationship with people, which might be a result of personal life experiences or some unresolved conflicts from another source.

The search for identity lies at the heart of any form of social anxieties. Often, if some fundamental questions about oneself can be answered the social anxiety decreases. Basic parameters are:

  • Needs
  • Values
  • Aspirations

(Haverkampf, 2018h)

An important method in therapy to have the client imagine a situation and run through it. This helps break down the distinction between reality and the imagined world. Many people suffering from social anxieties are very sensitive, which also contributes to the symptoms. Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. There may even be stammering and rapid speech. Panic attacks can also occur under intense fear and discomfort.

Many people with social anxieties have difficulties imagining the future because it is too painful. Here it helps to identify emotions and feeling that underlie the negative thoughts. Often the tensions and anxieties have underlying processes that need to be identified.

People with social anxiety often set high standards for themselves for social situations. Since they believe they cannot reach these standards they have a lot of negative thoughts about how they do in those situations and the outcomes. The sense of failure can be reinforced in the situation by very minor mishaps, such as a stutter or notices sweating. This leads to even greater self-consciousness and the likelihood actually of sweating or stuttering increases. Anxiety can increase to panic attacks.

‘Lost Opportunities’

It is also important to deal with the losses patients subjectively think they have incurred as a result of their social anxiety. People avoid situations where the social anxieties cause the symptoms. In more severe cases this can mean that the individual has no romantic relationships and does not take up jobs that could be interesting and enjoyable. Here the first step it to acknowledge the problem and realize that while one may not have done the preferred choice in the moment, social anxiety is often a problem of not knowing what one really wants. Finding this out can be a tremendous chance.

Judgment

The sense of being judged is quite common in social anxiety disorder. The judgment by others gets a relatively high significance. People with social anxieties can be very competitive in professional or academic situations. It seems easier to believe the judgment of others. The combination of a greater focus on oneself, being more alert to anything other people may see or perceive, and reduced trust in oneself and others frequently gives rise to the fear of being judged. If there is a greater disconnect from oneself and others, this can cause additional problems and potentially more anxiety.

There is a perceived need for a more complete control of one’s external communication, out of fear that the connection with the world could be lost, but this sought-after control by necessity also has to extend then to the internal communication, which destabilizes further can causes additional anxiety. The ultimate fear in social anxiety is not of social situations per se, but that connections and relationships could be lost forever. Fears of loss of relationships and loss of control is often at the heart of social anxiety. Helping people with social anxiety means exploring new ways of communicating, so that they learn that communication and relationships are in their essence quite predictable and stable.

Location

The setting can also play a problem and may be worthwhile to thematize. Instead of making a new friend at a bar, a person with social anxiety might find this task easier to accomplish via an online friendship or dating site. As patients develop a greater understanding of their wants, needs and aspirations, they also develop a better understanding of how they interact and communicate with their environment in ways that are more helpful, more efficient and better suited to their own needs and personality.

Treatment

he most well-researched psychosocial treatments for social anxiety disorder are cognitive-behavioral therapies (CBTs). However, there are several other therapeutic approaches which have shown promising in the treatment of social anxiety disorder. There are also various psychopharmacological approaches which demonstrate effectiveness.

Medication can help. From clinical experience the selective serotonin reuptake inhibitors (SSRIs), such as be helpful, particularly in the form of selective serotonin reuptake inhibitors (SSRIs) or sometimes serotonin norepinephrine reuptake inhibitors (SNRIs) if needed over a longer interval. Selective Serotonin Inhibitors (SSRIs) are often used in generalized social anxiety disorders, if psychotherapy does not help fast enough or as a support. Historically, paroxetine and fluoxetine have often been used, but newer SSRIs, such as escitalopram, seem also to work. In clinical experience, some people benefit significantly from SSRIs, while others do not. One explanation is that it depends on the presence of other symptoms and psychiatric disorders, as well as how generalized the symptoms are, or how specific they apply to certain situations. Overall, there can be many different reasons, especially psychodynamic ones, that make up this diverse diagnosis, and they need to be carefully explored to increase the chances of therapeutic success.

Cognitive-Behavioral Therapy (CBT)

Meta-analyses indicate that all forms of CBT appear likely to provide some benefit for adults. (Rodebaugh et al., 2004) On the behavioral side, exposure therapy, for example, involves exposing the patient to anxiety invoking interpersonal situations in a gradual fashion, beginning with less anxiety provoking scenarios, and moving up to the ones to which a greater level of potential anxiety is attached. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. (Craske et al., 2014) Exposure optimization strategies include the following:

  1. expectancy violation
  2. deepened extinction
  3. occasional reinforced extinction
  4. removal of safety signals
  5. variability
  6. retrieval cues
  7. multiple contexts
  8. affect labeling.

(Craske et al., 2014)

On the cognitive side, other techniques commonly used in CBT are to reflect on the negative thoughts and ruminations in interpersonal situations, identify unhelpful beliefs and biases, make more realistic probability estimates and use other more or less structured thought processes. The cognitive approach focuses mainly on intrapersonal rather than interpersonal processes. (Stangier et al., 2011)

Psychodynamic Psychotherapy

In a large multicenter study Leichsenring and colleagues used a manual-guided form of psychodynamic therapy that was specifically developed for their trial. (Leichsenring et al., 2013) It was based on Luborsky’s model of psychodynamic therapy, including supportive and expressive interventions. A secure helping alliance is an important element of the model. Expressive interventions relate the symptoms of social anxiety disorder to the patient’s underlying core conflictual relationship theme, such as a wish, an anticipated response and a response from the self, in order to reduce the symptoms of social anxiety disorder. (Leichsenring et al., 2013) The response from the self represents the symptoms of social anxiety disorder. The core conflictual relationship theme is worked through in present and past relationships as well as in the relationship to the therapist. (Leichsenring et al., 2013)

Mindfulness-based stress reduction (MBSR)

Mindfulness-based stress reduction (MBSR) has shown in several studies to reduce symptoms of stress, anxiety, and depression. MBSR is believed to alter emotional responding by modifying cognitive–affective processes. Since social anxiety disorder is characterized by emotional and attentional biases as well as distorted negative self-beliefs, this can be a helpful approach. MBSR training in patients with social anxiety disorder may reduce emotional reactivity while enhancing emotion regulation.

Goldin and Gross examined MBSR-related changes in the brain–behavior indices of emotional reactivity and regulation of negative self-beliefs in patients with social anxiety disorder. Compared with baseline, MBSR completers showed improvement in anxiety and depression symptoms and self-esteem. During the breath-focused attention task, they also showed decreased negative emotion experience, reduced amygdala activity, and increased activity in brain regions implicated in attentional deployment. (Goldin & Gross, 2010)

D-Cycloserine

Clinical data with specific phobias has suggested that the treatment effects of exposure therapy for SAD may be enhanced with D-cycloserine, an agonist at the glutamatergic NMDA receptor, and its use has been suggested for social anxiety disorder. In a study by Hofmann and colleagues, patients receiving D-cycloserine in addition to exposure therapy reported significantly less social anxiety compared with patients receiving exposure therapy plus placebo. Controlled effect sizes were in the medium to large range. (Hofmann et al., 2006)

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.

Introduction

We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal cords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life.

Communication as Autoregulation

Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.

If one suffers from social anxiety, this autoregulation seems to fail. One reason why it fails is because communication is such an important and basic process that there is nothing that could hierarchically control it and put a problem in it right. Only changes in communication can put a communication failure right. This is why a therapy that focuses on communication by identifying communication patterns and reflecting on them is in a good position to treat social anxiety.

Communication Patterns

Communication patterns are sequences in which meaningful information flows between individuals who are interacting with each other. A question in one person leading to an answer in another person is an example, which also illustrates how one communication pattern gives rise to another one. Communication patterns exist as templates in a social or cultural setting. They are activated and modified by the person using them. In a therapeutic setting one may, for example, look with patients at which communication patterns they use and how. Since meaningful information can only flow if it is transmitted within the dynamics of communication patterns, no matter how simple and rudimentary they may be, improving one’s selection and use of communication patterns also leads to a more efficient transmission of meaningful information. This is particularly useful in anxiety conditions, which are characterized by a subjective lack of meaningful information. Since a socially anxious person may actually be very sensitive and perceptive, and thus have more information about interactional clues and the other person available, the focus in Communication-Focused Therapy®, for example, is not necessarily the quantity of information, but how the patient finds, absorbs and processes the information which is most helpful to further the own needs, values and aspirations. In clinical experience, the more competent a patient feels in this regard, the lower the anxiety usually is. This applies particularly to social anxiety, where the anxiety revolves around external communication.

Attention

Attention is the ability to notice new information within a defined space, but also the capability to attach relevance to it.  Both attention and focus are important in the acquisition of meaningful and relevant information form the environment. If they are interfered with or misdirected, there is less relevant information available, which can increase the experienced anxiety. The attention of highly anxious individuals is more automatically captured by sub-threshold cues.  (Mogg & Bradley, 2002) Attentional bias toward negative social cues is thought to serve an etiological and/or maintaining role in social anxiety disorder. As discussed above, anxiety in general is a result of the subjective perception of missing relevant information. (Haverkampf, 2010a, 2018f)

Schmidt and colleagues tested in their study whether training patients to disengage from negative social cues may ameliorate social anxiety in patients with a primary diagnosis of generalized social anxiety disorder. Patients who underwent attention training exhibited significantly greater reductions in social anxiety and trait anxiety, compared with patients in the control condition. At termination, 72% of patients in the active treatment condition, relative to 11% of patients in the control condition, no longer met the DSM-IV criteria for social anxiety disorder. At 4-month follow-up, patients in the attention training condition continued to maintain their clinical improvement. (Schmidt et al., 2009)

Communication to Participate in Life

Communication is important to be connected into the web of life. The exchange of meaningful messages helps one to get what one needs, wants and aspires to. This applies to communication with oneself and others. Finding out what one needs, wants and aspires to happens through communication with oneself. It requires openness and insight.

The feeling of being a part of ‘the whole thing’ is important to an individual, not jut because the individual is part of a chain of generations. When one exchanges meaningful messages with others, oneself and the world around become meaningful to oneself. Losing a part of oneself or a loss of meaning, however, represents an existential threat, which can induce anxiety. This is how social anxiety and a loss in meaningful connectedness with others can lead to more anxiety. To an extent, this can be compensated for with meaningful communication with oneself, but for most this is not enough.

Understanding Social Anxiety and Shyness

Social anxiety is often present from childhood. The fears already interfere with one’s development early on. Since some of the most experiences in a human life are the interpersonal ones, this can interfere with one’s personal development. As already mentioned, shyness is not a disorder, and a person may be happy about it. However, the potential loss to quality of life of social anxiety and shyness can be similar. Shy people often develop adaptive communication pathways, such as relying more heavily on the Internet and may be content with it. However, interpersonal communication is an important piece of change and of bringing about in the world, and without it some of this dynamic may be missed out on. Given the many possible channels of communicating with the world, it does not matter so much which one is used. The important factor is that it allows the exchange of meaningful messages, which aid the individual in becoming better connected with oneself and the world.

Internal Communication

Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Individuals with social anxiety are often very critical of themselves, and this is what is then projected into others, who then appear critical of oneself. An important, and often helpful, step is to become aware of this.

The internal and external communication go hand in hand. Thought patterns that are used in one’s communication with oneself are usually also used in the communication with others. If there are doubts and fears in the communication with oneself, they often will also be present in one’s communication with others.

Uncertainty

In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst-case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.

Studies have shown that the intolerance of uncertainty explains a significant amount of variance in social anxiety severity when controlling for several cognitive correlates of social anxiety, such as the fear of negative evaluation, and for neuroticism. Intolerance of uncertainty also seems to be related with symptom levels of GAD, OCD, and social anxiety, but not depression. (Boelen & Reijntjes, 2009) It seems to play a significant role in performance and interaction social anxiety, but probably a slightly greater role in the former. (Whiting et al., 2014) Intolerance of uncertainty also appears significantly associated with symptom levels of separation anxiety disorder. (Boelen et al., 2014)

Communication Deficits

Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, stay unresolved. For example, if a parent feels fearful and angry with himself and this is picked up by a child, the latter may decode these messages correctly in that the parent is angry, but since the parent may not be conscious about it, the child does not pick up on the second important half of the message, that the parent has a problem with himself and his issue is unrelated to the child. Of course, one can learn to pick up on the self-blame and frustration of the parent, and therapists should become experts at reading between the lines in this fashion, but it requires experience, reflection and insight into transference and counter-transference phenomena, for example, to use the psychoanalytic terms.

In one study, hildren with social anxiety disorder scored significantly higher than anxious children without on the Social Communication Questionnaire (SCQ), reciprocal social interaction, communication and repetitive, restrictive and stereotyped behaviors subscales. They were also three times more likely to score above clinical cut-offs overall. (Halls et al., 2015) This shows that these children have difficulties with certain communication patterns. However, this may not be due to a social skills defict, but they may believe that they appear nervous during social encounters. (Cartwright-Hatton et al., 2005) It would further support the view that it is the flow of information, internally and externally, which is really at the base of social anxiety disorder and many other mental health conditions (Haverkampf, 2018b). These can, on the other hand, be influenced and changed through work on the communication petterns and individual uses.

Avoidance

Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run. While smaller skillsets seem to pla role, it is also important to keep in mind that the avoidance of internal and external flows in itself lowers the available quantity of meaningful information, which plays a significant role in increasing uncertainty about the world and oneself (Haverkampf, 2010a) and thus the levels of anxiety, while holding the tolerance for uncertainty constant.

Meaning

Individuals suffering from social anxiety do not see less relevance in social interactions, but often even more. It is not necessarily seeing more meaning, though, but a different kind. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

However, someone with social anxiety may see the meaning in things differently from someone what does not suffer from it. Approaching someone of the opposite sex may be seen differently because of life experiences. Also, if different meaning is seen in it, the expectations can be different. Expectations that are so high that they are self-defeating can be a problem. However, to set expectations that are not too high and not too low mean having a view of reality that works for oneself.

Awareness of Thought Patterns

An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty is quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing psychologically and the feelings of a dreaded uncertainty about oneself and one’s emotional states.

Awareness means observing the own thought patterns and gaining insight into them. This requires being receptive to this information from oneself and the ability to reflect on it. Important is being able to perceive the flow of information between the parts of oneself, and the ability to let the information flow freely.

Flow of Information

A free flow of information within oneself and with the environment is important to reduce the anxiety and physical symptoms associated with social anxiety. Often, such an openness has become difficult for people because of inadequate interaction patterns and a fear to change anything. In a therapeutic session, this can be changed in two ways. Interaction patterns can be experimented with in a therapeutic session and reflected upon. One objective should be to help the patient develop greater efficacy and confidence in his or her interactions with the environment.

Emotional Reconnection

If there have been adverse life experiences as a significant factor in the social anxiety, there can still be unresolved emotions underlying the anxiety. To resolve them means answering the hypothetical question, what one may have felt in the difficult situation, but then also seeing the strength that allowed one to pull through, which only becomes visible now. The goal is not necessarily to reconnect with only negative emotions form the past, but also the good ones, and emotions as a whole today.

If there is a disconnect, and emotional reconnection would be helpful, one should approach one’s feelings gradually. Especially in cases of social anxiety, it could be problematic trying this too fast. In any case, as internal and external communication go hand in hand, so do internal and external emotional connection. Someone who is disconnected from oneself will have a more difficult time to emotionally communicate with others or stay reflected and calm in situations where there is a potential for greater emotional communication, such as in romantic situations.

Experiencing the World

Social anxiety means potentially experiencing less of the world, although the higher sensitivity can at the same time let someone experience more. It is important again to note that many patients suffering from social anxiety disorder put themselves under an enormous pressure. Their more frequent feeling that they need to interact with others and live their lives in certain can add to the anxiety, rather than diminishing it. The more permanent solutions to this dilemma are, as outlined above, a greater connectedness with oneself and better insight into the own needs, values and aspirations. Work with the communication patterns a patient uses, as well as reflection on how she felt when engaged in activities and with other people in the past, sheds light on the ‘truer’ needs, values and aspirations. The focus is here completely on the patient and her experiences, not on the expectations of others. This focus establishes more meaning in the life of the patient and helps is the acquisition of more helpful communication patterns.

Communication Techniques

Various communication techniques can be helpful, not as an end in themselves, but to help the person have more confidence in oneself and to see communication not as something dangerous one needs to be guarded against, but as something that can help one meet one’s needs, wishes and expectations. Thus, the reason for communication techniques should be not an end in itself, but to increase one’s repertoire, ease and confidence in communicating with oneself and others.

Openness to others, a positive and welcoming attitude towards the messages of others and engaging in reflection on the interaction are some helpful approaches towards communication, but there are many others as well. Important is not to be deterred from the interaction when something unsuspected or disappointing happens, but to reflect on what it could mean, whether it is a message from outside or inside oneself. Genuinely new information is never meaningless and reflecting on it helps to gain more insight into the world. Social anxiety, on the other hand, is often a result of engaging with messages only superficially, rather than letting them resonate with oneself and determining what they might mean.

Technology can also play a useful role in gradually exposing oneself to potentially more anxiety provoking situations. For example, beginning with interactions with fewer communication channels, such as an online dating site, can make it easier to then move on to an in-person date. More information could already be screened in a less communication intensive setting before exposing oneself to the many communication channels of an actual physical date. Pierce demonstrated in a study a positive relationship between social anxiety (not comfortable talking with others face-to-face) and (1) talking with others online and (2) talking with others via text messaging. In contrast, there was a positive relationship between the lack of social anxiety (feeling “comfortable” talking with others) and making friends online. (Pierce, 2009) Gender differences were also pointed out in the study.

Breaking the Cycle of Anxiety

To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.

Insight and connectedness reduce anxiety. Openness and receptiveness to information and messages can lead there. This can be practiced in therapy and brought from there into everyday life. The sense of competence helps build confidence in dealing with oneself and the environment. Important is to connect with oneself to a level that there is greater insight into what is truly important to oneself.

The Reward of Seeing More

Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it. People with social anxiety often see less in an interaction, although they often have a greater sensitivity and perceptiveness to see more. This has to do with a different focus on where to find a relevant and meaningful message in the interaction. For example, in an interaction with a romantic love interest, the socially anxious person may be too focused on signals and own thoughts about a possible rejection rather than on information from the other person that could help in getting to know that person.

An important step is therefore to become aware that what may be behind some of the social anxiety, or much of it, is actually something quite positive, something that can be used to one’s advantage. Central is merely how to use a heightened percetiveness and sensitivity to certain information signals for one’s benefit rather than to one’s detriment. In Communication-Focused Therapy, through work on communication patterns, within and without oneself, the selection and steering of information flows can be changed, which also directly impacts the information and meaning a person is exposed to. Since anxiety is tightly linked with the flow of information and the available information, changing internal and external communication patterns can lower anxiety quite substantially (Haverkampf, 2013, 2017i, 2017b).

Values, Needs and Aspirations

Beyond food, drink, a roof over one’s head and basic safety, humans have values, needs and aspirations that drive much of what they are doing throughout their lives. None of us is born to live the life of a Robinson Crusoe, and just like the fictional character, interpersonal interactions with others, as well as the intrapersonal communication that is tightly lined with it, are the main instruments to get these needs, values and aspirations met. The exchange of meaningful information is what brings about positive and lasting change in oneself and in the environment (Haverkampf, 2010b). The author has referred to the own needs, values and aspirations before as basic parameters because they can determine whether some information that has become available in a person is meaningful or not (Haverkampf, 2018h).

One of the most painful elements of social anxiety is that a person finds it more difficult to find the own needs met. It interferes with dating, in workplace situations or in academia. People suffering from this condition, do so in silence, which tends to make it even worse. To escape this vicious cycle, a new orientation towards the own values, needs and aspirations is needed (Haverkampf, 2013, 2017e). What helps to achieve this is through a better connectedness with oneself and others. The work on communication patterns in Communication-Focused Therapy can here be very helpful (Haverkampf, 2017e).

The Need for Communication

Living organisms constantly need to communicate within themselves and with others, and humans are not an exception. Close relationships in humans, for example, have been linked to a wide variety of psychological and other processes, including physical and mental health (Jones et al., 1990). Communication with others is needed to grow, innovate and propagate. Most of the human accomplishments in the arts, sciences and professions are based on the exchange of meaningful messages, communication. But communication is also to have one’s needs met and to survive in general. Even a hermit in the mountains needs to interact with his or her living mountain environment. People who enjoy nature usually do not want to shun communication but focus on an exchange with a nonhuman environment. Communication is fundamental to life itself.

Suffering from social anxiety does not mean a disinterest in people or an objection to being with them, rather the opposite. An indifference ot something does not lead to anxiety or the feelings that are commonly experienced by indidividuals with social anxiety. The latter are testamount to the importance a person with social anxiety attaches to interpersonal connections and the social realm. People with social anxiety may even be more sensitive and perceptive to social signals, though they may be minterpreted, and to the importance of social interactions. In one study, perceived closeness was greatest when the most socially anxious individuals interacted with each other (Kashdan & Wenzel, 2005). At the same time, in another study, when asked how an investigator viewed them based on that person’s facial expressions, socially anxious subjects made ratings that were consistently less favorable than the ratings made by subjects lower in social anxiety (Pozo et al., 1991). In other words, we have the semmingly paradoxical findings that people with social anxiety may experience social connections even mor eintensely, while possibly doubting them more in other situations. One explanation would be the fear of losing something very important. The more important social connections are to a person, the higher may also be the apprehensiveness about doing something wrong and losing it. Adding in higher anxiety levels to begin with, might give us a fairly adequate representation of the underlying dynamic in social anxiety.

Experimentation with adjustments to existing communication patterns and the development of new ones is the road that leads to less social anxiety (Haverkampf, 2017e, 2018d). The first steps can often be quite small for good reasons. It often helps people with social anxiety and shyness to connect with and appreciate their need and joy in communicating. Once communication is seen as a potential source of pleasure rather than a necessary task, it can become much easier, as ‘I want’ replaces ‘I should’. It often helps to take on a more investigatory perspective, donning a lab coat so to speak, and having fun observing the communication dynamics as they unfold in an interaction. The benefit is often twofold. Once one takes on an observer role it is easier to extricate oneself from the emotional vortex of being caught up insight a problematic interaction, while being able to better reflect and understand the dynamics. The greater awareness and space to experiment with new communication elements and patterns either in the current or a future situation can lead to a massive change in how effectively and satisfyingly one interacts with oneself and the world and thereby fulfils the own needs, values and aspirations.

Meaningful Messages as the Instrument of Change

Communication is the vehicle of change, and meaning drives it. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings about change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist. Over time, changes and sjudtments to in internal and external communication patterns facilitate a greater awareness for and processing of meaning (Haverkampf, 2010a, 2017c, 2018i).

Information underlies practically everything from physical quantum states and classical processes to psychological ones (Haverkampf, 2018g). Information Perceived emotions are also communicated information (Haverkampf, 2012b). In an interpersonal conext, meaning is generated from the information carried by signs.  Creation of meaning events in-therapy, for example, are change episodes that occur when a patient seeks to understand the meaning of an emotional experience (Clarke, 1996). Meaningful information is information which can bring about a change in the recipient of the information (Haverkampf, 2010a, 2018a). It has also been argued that information is objective, but inaccessible to humans, who exist exclusively in a world of meaning, while meaning is intersubjective, or based on shared agreement and understanding, rather than purely subjective (Mingers, 1995). However, the description of meaning as information that carries the potential to effect change may allow for a broader and more generally applicable delineation of the term. In Communication-Focused Therapy it is an important means of change dependent on the effective communication of the information that codes for it. Social anxiety illustrates quite brightly what happens when the process at one or more points affected by other factors, either within or outside the person. Social anxiety is primarily a communication problem, often alongside or based on generally higher levels of anxiety.

Embracing Change

In the case of social anxiety, embracing change can be associated with anxiety, while it can also be liberating because it means that there are no rigid rules one needs to adhere to other than those linked to the communication process itself, which has clear laws. Understanding these laws of communication, on the other hand, which humans subconsciously operate on and use as they accumulate experience in their interactions with others is essential to gain greater confidence in tolerating and working towards change. Basic communication concepts, such as what constitutes communication, how meaning is created, how information flows, and how communication processes are influenced, is usually not conscious. Reflecting on it and beginning to use it, however, can be especially helpful to sensitive people, who quite frequently have experienced social at some point in their lives. One might say that only those who do not care about people and themselves are entirely free from social anxiety, but this tantamount to the description of a sociopathic personality disorder.

Change should thus not be understood as changing oneself or one’s ability to perceive and be sensitive to the nuances of daily interactions, but to develop new communication patterns. Some of the techniques used in Communictaion-Focused Therapy have been described elwhere (Haverkampf, 2017a, 2017e, 2017i, 2018e). Important is the concept that external and internal communication patterns are closely related to each other, and that work on communication in therapy leads to change on both sides. Several of the techniques involve the use of certain communication elements and structures, such as a variety of the question (Haverkampf, 2017g) and other functional concepts.

Living

It is not the number of social contacts which is relevant. Having a few good friends is often worth more than thousands of contacts in an online social network. However, this does not mean friends have to be always physically present. Meeting friends online also allows for communication, while close physical contact in an intimate relationship is to most people important on a regular basis.

Important is that the communication patterns, the frequency and the interaction style fit the needs, values and aspirations of the individual. People who are shy can be quite happy with the intensity and frequency of their interactions, those with social anxiety are usually not. It is thus important to help individuals with social anxiety discover what is important to them and how they want to live their lives. Communication patterns change more easily when the change creates more meaning in the world of the patient (Haverkampf, 2012a). Communication-Focused Therapy thus aims first at creating greater awareness for the basic parameters of needs, values and aspirations to support the process of change in communication patterns (Haverkampf, 2010b, 2017a).

In the end, communication is an activity. One ultimately needs to do it. However, when one has worked on the own communication, developed awareness for them, gained insight into them and made it a habbit to experiment with them, communication becomes something to look forward to rather than something that causes apprehensiveness and anxiety.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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Psychiatry (3)

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Psychiatry

Christian Jonathan Haverkampf M.D.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Working on internal and external communication is a central focus in psychiatric treatment.

Keywords: psychiatry, psychotherapy, communication, medicine

Contents

Introduction. 3

Communication. 4

Biological and Social Science. 5

Approaches. 5

Software and Hardware. 5

The biopsychosocial Model 6

Diagnostic systems. 6

Diagnostic manuals. 7

Assessment. 8

Medication. 8

Psychotherapy. 9

Medication and Psychotherapy. 10

Ethics. 10

Health. 11

Into the Future. 11

References. 12

Introduction

The question what psychiatry is begins with the definition of the term ‘psyche’. The term “psychiatry” was first coined by the German physician Johann Christian Reil in 1808. The ancient Greek term ‘psyche’ is often translated as ‘soul’. However, it can also mean ‘butterfly’. While psychiatry was up until about a century ago more an occult art than a science, this has changed dramatically in the twentieth century. Within the last century, psychiatry began to make its terms, observations and inquiry much more structured and ‘scientific’.

Psychiatric illnesses all have in common that communication with others and the own person is disturbed. (Haverkampf, 2010b) These maladaptive communication patterns lead to the symptoms which are commonly observed. For example, in a case of schizophrenia the source of incoming information can no longer be correctly attributed to the outside world or the inside, and in a case of anxiety emotional signals are no longer correctly identified and processed. Communication, the transmission of messages, adheres to rules like any other natural phenomena and is relied on in nature from information carried in a beam of light to cells exchanging DNA. Humans can observe and reflect on these flows of information, also on information flows within themselves. The sense of self and the attribution of a mind to someone or oneself is a result of the ability to observe these flows of information, and as such of the communication one has with oneself or the world around.

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It is devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Psychiatry focuses on the interaction between patients and therapists in a way, which no other medical specialty does. While it is true that psychiatry has become more biologically based over the last century, it has also begun to look at the finer details of information transmission in the neuronal networks of the brain. Fortunately, gone are the times of lobotomies, where parts of the brain were removed, to make way for much more specific and finer treatment interventions, whether with psychotherapy or medication that works on specific neurotransmitter receptors or mimics certain neurotransmitters. The elaboration of the information transmission at the synaptic level has given us clues on how psychiatric illness is maintained, and medication works, within the larger system of an individual’s neuronal network.

The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of “nerves”, and psychiatry linked up with neurology and neuropsychiatry. Sigmund Freud, who early in his career searched intensively for explanations of psychiatric phenomena on a neuronal level, initiated the development of psychoanalysis, which shifted the emphasis on communication as an important instrument in the healing process. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices at a time when effective psychiatric medication was still in its infancy.

Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine, which became the first neurotransmitter to be described. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate’s ability to stabilize mood highs and lows in bipolar disorder in 1948. Neuroimaging became an investigatory tool in psychiatry in the 1980s.

Communication

Psychopharmacological changes in the neurotransmission systems, the information interfaces where electrical signals are translated into chemical signals, and back again, affect how and what information is being transmitted. This in turn has an effect on a person’s internal communication and his or her communication with the external world, which are also the target of psychotherapy. (Haverkampf, 2010a, 2017c) Medication and psychotherapy can thus work together synergistically.

Unlike physicians in other medical specialties, psychiatrists specialize in the doctor–patient relationship and should be trained extensively in the use of psychotherapy and other therapeutic communication techniques. Unfortunately, this is not always the case, which can reduce the effectiveness in treating a mental health condition significantly, because treatment of a mental health condition implies working with and understanding communication on different levels. The patient uses communication with other people and the self-talk with him or herself to meat own needs, values, wishes, desires and aspirations, requiring a holistic approach to the communication patterns and mechanisms a patient uses.

Since communication plays such a central role in psychiatric treatment, the author has developed communication-focused therapy (CFT), which focuses on internal and external communication patterns to relieve the symptoms of a wide variety of mental health conditions (Haverkampf, 2017a, 2018c).

Biological and Social Science

Psychiatry is the most multidisciplinary medical specialty using research in the field of neuroscience, psychology, medicine, biology, biochemistry, even physics, and pharmacology. Since psychiatry looks at the patient who is interacting with the larger world around, the social and communication sciences, including even behavioural economics, and the humanities can make important contributions to the field of psychiatry. If one considers psychiatry as a specialty that focuses on improving meaningful communication within wider information systems, the biological and social viewpoints merely represent looking at the same processes with different magnifications.

Psychiatry addresses internal and external communication issues, which are usually multifactorial in their aetiology. Compliance and the effects of medication and psychotherapy depend on the interactions between the patient and the environment. There are branches of psychiatry which look at different environments and how they influence the mental well-being of a patient. Unfortunately, psychiatric hospitals and various public health clinics have been notoriously slow at implementing any recommendations from this research.

Approaches

Psychiatric illnesses can be conceptualized in several different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. However, unlike the other fields of medicine, psychiatric diagnoses say little about underlying causes on a biological level but are mostly groupings of symptoms which seem to appear together. This is not to say that such groupings are not helpful. They can make it easier to describe conditions and often make it easier to pick specific therapeutic approaches and types of medication. However, since individual symptoms overlap and due to the complexity of the neural networks, it is usually not possible to follow a group of symptoms back to a specific biological variation. Since the brain is highly plastic, synapses rearrange their connections with each other all the time and assign varying weights to them. This means that a symptom of anxiety, for example, can be triggered by information stored over millions of nerve cells, and merely understanding how a biological component, such as a receptor, works does not help in understanding or treating the symptom.

Software and Hardware

Psychiatry is both ‘software’ and ‘hardware’ oriented, where ‘software’ refers to the information stored in the neural network and ‘hardware’ to the cellular network on a biological level. In the latter, there is an overlap with neurology and other medical sciences. What sets psychiatry apart is particularly the concern with information, the flows of information and how information is processed. New diagnostic systems and schemata have been developed on the psychotherapy side, which pay greater attention to the information dynamics. These models and systems can provide additional information to an experienced clinician who can then integrate these additional aspects with the diagnostic systems from the traditional medico-psychiatric side.

The biopsychosocial Model

The biopsychosocial model is commonly used to describe the three factors that play a role in the development and maintenance of a psychiatric condition:

  • Biology
  • Psychology
  • Environment (social)

What is striking about these three domains is that all consist of the transmission of information in one way or another. Some describe more the internal communication (biology, neuroscience, psychology), while others describe the external communication (psychology, sociology, economics and others), but all work in parallel all of the time. Psychiatry thus works with very complex systems, which are much more elaborate than in any other field of medicine. This may also be the reasons why psychiatry was the field within medicine to develop rather late, because it uses the insight gained in several other fields.

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole, this remains a research topic.

The problem with most diagnostic systems in psychiatry is that they do not address the underlying causes of an illness but focus instead on bundles of symptoms. As a descriptive system this makes sense in many instances. However, from a treatment perspective this is often unhelpful. Since medication works on underlying neurotransmission system within a vast network of interconnected neurons, a system that makes diagnosis based on properties within that system and on the individual neuronal level would be more helpful. From a psychotherapeutic perspective, a focus on internal and external communication would be helpful. Both perspectives could lead to systems that would be compatible with each other or even to one system that combines features of the two.

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The International Classification of Diseases (ICD-10) is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V), produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States, although the ICD-10 has official status there as well. It is currently in its fifth revised edition and is also used worldwide. As already mentioned, the diagnostic systems are based on bundles of symptoms. Psychiatry has “a syndrome-based disease classification, which is not based on mechanisms and does not guide treatment, which largely depends on trial and error” (Stephan et al., 2016). The author of this article would not go so far. Greater clarity about a diagnosis or several diagnoses, even if we do not understand fully the underlying biological and psychological mechanisms, can be an important tool in formulating a treatment plan, which often also includes medication (Haverkampf, 2018a)

The diagnostic manuals overlap to a significant degree. One reason is that they describe groups of symptoms which are often seen together, and over time the use of their diagnostic terms has made it easier to provide treatment and conduct research. However, both suffer from the critiques mentioned above. They can give a rough idea of the symptoms, a suitable therapy and the prognosis. However, since the diagnostic systems say nothing about the underlying causes, the actual therapy needs to be individualized and its success depends on several factors inside the person and in the environment. Looking at the patient’s internal and external communication can help individualize the therapy. (Haverkampf, 2010b, 2012, 2013a, 2013b)

It is important to keep in mind the purpose served by diagnosis. It is ultimately to help a patient and raise his or her quality of life. While there may be other uses of it for forensic, insurance or other purposes, they should not lead to a different interpretation of what a diagnosis is for in a treatment context. Diagnoses can at least help to raise the probability that a specific medication or group of medication will alleviate certain symptoms (Haverkampf, 2018a, 2018f).

Assessment

The first step in treatment is traditionally assessment. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

However, especially in psychotherapeutic treatment, assessment can still take place after the therapy has commenced. While it is important to have a working hypothesis for the condition, it is important to remain open to any new insights gained from observing and interacting with the patient over time. For this, it is important to be in the interaction with the patient, yet also to be able to take a step outside of the interaction and reflect on the communication dynamics.

Assessment with a focus on the internal and external communication can identify problems which are leading to the symptoms. This information is then helpful to make better decisions with respect to medication and psychotherapy. Communication-Focused Therapy, as developed by the author, focuses on communication patterns an individual uses, whether in everyday life or in a therapeutic setting (Haverkampf, 2010b, 2017a). Rather than looking primarily at the content of what is being communicated, the how it is communicated assumes an additional particularly important role. Since people, and all other living organisms, meet their needs and aspirations through the exchange of information withing themselves and with the world, it is important to encourage awareness, reflection and experimentation with communication to make it more efficient and satisfying for the individual. As life aligns more with the basic parameters, the needs, values and aspirations, as a result of better communication, the symptoms of a mental health condition often receded (Haverkampf, 2017f, 2017b, 2017d) .

Medication

Psychiatric medication represents a very heterogenous group of substances, which are among the most widely prescribe in the world. Psychiatric medication was usually available before one had an understanding for its effects on a cellular or neural network level. However, in all cases it has been shown that psychiatric medication affects the information transmission in the brain. This is a point where psychotherapy and medication could go well with each other hand in hand (Haverkampf, 2018f).

The efficacy of medication can often very significantly among individuals. One antidepressant from the most popular group of antidepressants, the selective serotonin reuptake inhibitor (SSRI), for example, may help against the symptoms of depression and anxiety, while another from the same group does not work in the same patient. The outcome is not always easy to predict, although one can have a sense of the medication that is most likely to work. It requires a proper assessment in the first place, but also a solid understanding of the desired changes and the expectations of the patient.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance, full blood counts serum drug levels, renal function, liver function, and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for severe and disabling conditions, such as those unresponsive to medication. Although the literature reports on successes in treatment-resistant cases, its use remains controversial. Often, the available treatment options with medication and psychotherapy have not been fully exhausted when considering ECT.

To summarize, one may say that the support available form medication can be life-changing in some cases and increase the quality of life significantly. In contrast, in others, it may do little or lead to side effects, or there can be both positive and negative effects side by side. Several parameters have been studied to shape the recommendations of the professional. For example, in a study on the variables that could predict a successful treatment outcome in depression, chronic depression, older age, and lower intelligence, each predicted relatively weak response across psychotherapy and medication. On the other hand, marriage, unemployment, and having experienced a higher number of recent life events each predicted superior response to cognitive therapy relative to antidepressant medications (Fournier et al., 2009).

Psychotherapy

As already mentioned, increasingly psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of “talk therapy.” This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

However, this approach is short-sighted. It may be easier to prescribe medication, which is a concept familiar to most patients, than to explain how psychotherapy works, whose basic premises, tools and approaches are less well known. Psychotherapy often delivers a lasting effect in the long-term in cases of anxiety, mild to moderate depression and several other conditions, which goes beyond the ongoing support medication can offer (Haverkampf, 2017a). The reason is that changes in the internal and external communications usually bring about changes in a patient’s symptoms (Haverkampf, 2018d). While medication also has an effect on these communication patterns and, through learning effects, it can even last for some time after the drug is discontinued, the changes are usually less specifically tailored to the needs and personal history of the patient.

Medication and Psychotherapy

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. In many cases, a combination of psychotherapy and medication can prevent relapse longer than either treatment type on its own. (Haverkampf, 2018f, 2018e) There is a substantial synergism between the two. Medication can provide the support which facilitates psychotherapy, while psychotherapy can increase the compliance with medication.

Ethics

Most unethical treatments in psychiatry have been a result of neglecting the importance of communication in treatment and seeing properties of interactions as being localized in a particular area of the brain rather than occurring in a network internally and through interactions with the world externally. Much unethical behaviour in psychiatry can be summarised by saying that the physician failed to interact, communicate and understand a patient in any meaningful way. When knowledge about psychiatric conditions is seen separate from the interaction with the patient, it becomes akin to playing the lottery of sorts. Treatment requires a focus on how the patient communicates internally and externally and how the world responds to these messages.

When a psychiatrist is connected on emotional and cognitive levels with himself or herself as well as the patient and has healthy boundaries in place, ethical lapses become less likely. However, this often requires substantial experience and skills in a psychotherapeutic technique that focuses on insight. It requires an interest in and experience with human communication.

Health

To have a definition of illness, one needs a definition of health. Psychiatry is not only concerned with psychiatric illness but largely also with the maintenance of mental health. Insight into the aetiology and pathogenesis of burnout, for example, helps to prevent it, (Haverkampf, 2013a, 2013c, 2017g, 2018b) which is not only good for the individual but society and the economy as a whole. (Haverkampf, 2013c) Knowledge about which work and communication environments are helpful in preventing a relapse of psychosis can help a person arrange life in ways which keep him or her mentally healthy for as long as possible. (Haverkampf, 2017e) Skills in connecting with oneself can help to understand the information contained in emotional signals underlying episodes of anxiety. (Haverkampf, 2012)

Into the Future

The biopsychosocial model reduces to the communication model. Internal communication and external communication are, to some extent, arbitrary distinctions because communication still adheres to the basic rules and laws of communication, whether it unfolds in a person or without. However, this requires an integrated and more universal view of mental health. What makes us all human are the mental processes which give us the ability to observe and reflect on these flows of information. Psychotherapy and medication are the tools to bring about change in these communication patterns, internal and external ones. Other supportive therapies, such as occupational therapy, meditation and various forms of bodywork, can provide crucial additional support towards a satisfied, content and happy life, one in which personal needs, values, wishes, desires and aspirations can be met.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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The Misdiagnosis of ADHD in Adults (1)

The-Misdiagnosis-of-ADHD-in-Adults-1-Christian-Jonathan-Haverkampf-psychiatry-series-1

The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11

CAADID.. 12

DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25

 

Introduction

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)

Attention

When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)

Communication

The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).

Autism

Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).

Trauma

Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).

OCD

Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).

Symptoms

Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.

Subtypes

It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)

Assessment

The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.

Communication

How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.

CAADID

The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)

DIVA

Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.

Questionnaires

Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.

Malingering

Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).

Comorbidity

High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).

Conclusion

Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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Body Work and Exercise for Anxiety Panic Attacks Depression and OCD

Body-Work-and-Exercise-for-Anxiety-Panic-Attacks-Depression-and-OCD-2-Christian-Jonathan-Haverkampf-life-improvement-series

Body Work and Exercise for Anxiety, Panic Attacks, Depression and OCD

Christian Jonathan Haverkampf, M.D.

Working with the body is often neglected in major schools of psychotherapy, such as psychodynamic psychotherapy and CBT. Depression and anxiety disorders are some of the most prevalent psychiatric disorders with close to one in five of adults exhibiting symptoms. Exercise has been shown to reduce symptoms associated with these disorders, has the potential to increase the effectiveness of psychopharmacology and to reduce depenndance on it in specific cases. The balance seems to be important between too little and excessive exercise.

Keywords: body work, exercise, treatment, anxiety, panic attacks, depression, OCD, obsessive-compulsive disorder, Communication-Focused Therapy, CFT, psychotherapy, psychiatry

Contents

Introduction. 4

Reconnection. 4

Communication. 4

Information Processing. 4

Integrative Therapy. 5

Exercise and Mental Health. 5

Depression and Anxiety. 5

Age. 6

Neurophysiology. 6

Hippocampal Volume. 6

Endocannabinoids. 6

Adrenocorticotropic Hormone (ACTH) 6

Serotonin. 7

Depression. 7

Body Image. 7

Body Image as a Problem.. 7

Obesity. 9

Breast Cancer. 9

Exercise as an Adjunct to Medication. 10

Techniques. 10

Basic Body Awareness Therapy (BBAT) 10

Pilates. 11

Body Psychotherapy (BPT) 11

Tai Chi 11

Yoga. 11

Exercise Dose. 12

Exercise and Anxiety. 12

Anxiety Sensitivity. 13

Body Dysmorphic Disorder: OCD.. 13

Hypochondriasis. 14

Risks. 15

Prevention. 15

Conclusion. 15

References. 17

Introduction

Much of the information the brain processes is received from and through the body. Since anxiety, depression and OCD are disturbances in the communication and processing of information, it makes theoretical and practical sense to involve the body in the therapeutic process.

While studies support the use of exercise as a treatment for depression, healthcare professionals irregularly suggest and rarely prescribe it. In their depression treatment guidelines, the American Psychiatric Association (APA) states that exercise may be of value but does not consider it as a first-line treatment. The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy.

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. Besides case series and small uncontrolled studies, recent well-controlled studies suggest that exercise training may be clinically effective, at least in major depression and panic disorder. (Ströhle, 2009)

Reconnection

Information comes in through the body. Types of body work and exercise which increase the sense of the body appear to be helpful in various psychiatric conditions. It helps to lessen the focus on a particular bodily function or organ and opens the inflow of information from more points in the body. This can help lower the partial disconnect which is usually present in conditions, such as anxiety, depression, panic attacks, OCD and more.

Communication

The body is a communication device, receiving information from the environment and allowing one to send messages, whether verbal or non-verbal. (Haverkampf, 2018) Communication is also the process which brings about change (Haverkampf, 2010a) and takes a preeminent place in communication-focused therapy (CFT) (Haverkampf, 2017a), which has been developed by the author, and plays a role in all psychotherapies.

Information Processing

The body also uses information that is communicated to it. As the nervous system innervates most parts of the body, there is a fast and ubiquitous connectedness throughout the body. While much information is relayed in the central nervous system (CNS) and then send out again, there are relatively autonomous neural networks distributed throughout the body. From a communication viewpoint one needs to look at them as doing something similar to the brain, though on a simpler level. Information is received, processed and new information is sent out again.

Integrative Therapy

The work with the mind and the work with the body in various shapes and form should be seen as two ways to work on communication systems inside the person. The objective is to make communication work better for the patient. This may require a new perspective on how the mind and the body interact, but communication is how things get done inside the body and with the rest of the world.

Exercise and Mental Health

Early large population studies examined the relationship between exercise behavior and mental health . The relation between self-reported physical activity and depressive symptom was analyzed for 1,900 healthy subjects aged 25–77 years in the Epidemiologic Follow-up Study (1982–1984) to the first National Health and Nutrition Examination Survey (NHANES I) and found that physical inactivity may be a risk factor for depressive symptoms.

Weyer found the odds ratio for depression to be significantly higher (OR 3.15) for the physically inactive compared to regular exercisers in a sample of 1,536 individual 15 years of age and older.

Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies. For example, in a nationally representative sample of adults ages 15–54 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders.

Depression and Anxiety

There is a general belief that physical activity and exercise have positive effects on mood and anxiety and a great number of studies describe an association of physical activity and general well-being, mood and anxiety. (Ströhle, 2009) In a study of 19,288 individuals, De Moor found that regular exercise was associated with lower levels of depression, anxiety, and neuroticism.

Cooney and colleagues conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register up to 2013, www.controlled‐trials.com, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform and any potentially eligible trials not already included are listed as ‘awaiting classification.’ Exercise appeared moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only showed a smaller effect in favor of exercise. When compared to psychological or pharmacological therapies, exercise appeared to be no more effective, though this conclusion was based on a few small trials. (Cooney et al., 2013)

Habitual exercise correlates to a heightened level of mental health and wellbeing and reduced feelings of anxiety regardless of the gender of the individual. Relative increases in maximal cardiorespiratory fitness and habitual physical activity appear to be associated with lower depressive symptoms and greater emotional well-being. Ohta noted that 30 minutes or more of walking or cycling while commuting to work might be associated with an increased perception of mental health in men.

Age

The age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents. In contrast, Fox found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity.

While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psychological disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety.

Neurophysiology

Physical activity and exercise have been shown to induce widespread neurobiological adaptations. Imaging studies have demonstrated structural changes associated with early-onset depression in the hippocampus, amygdala, striatum, and frontal cortex; areas that are all extensively interconnected. Most consistently associated with depression are the findings of volume loss in the hippocampal formation. Increased levels of hippocampal brain-derived neurotrophic factor (BDNF) levels are associated with decreased anxiety. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity (Portugal et al., 2013).

Hippocampal Volume

As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume. Brain neurogenesis is increased by antidepressant medications. Ernst and colleagues hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. They outline four possible molecular mechanisms for this increased neurogenesis, all of which both promote hippocampal neurogenesis and increase with exercise: B-endorphins, vascular endothelial growth factor, brain-derived neurotrophic factor, and serotonin.

Endocannabinoids

Other possible mechanisms for exercise’s ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being.

Adrenocorticotropic Hormone (ACTH)

Changes in the hypothalamo-pituitary adrenal axis, including increased adrenocorticotropic hormone (ACTH) and decreased cortisol production, are associated with exercise and thought to be part of the mechanism of its positive effects on mood.

Serotonin

A randmoised prospective study by Wipfli and colleagues showed that the exercise group had lower levels of depression than the stretching‐control group after the intervention. The exercise group also showed a larger percentage decrease in serotonin than the stretching‐control group. This reduction in blood serotonin after exercise is similar to the effects of selective serotonin reuptake inhibitors. Additionally, percent change in serotonin was found to partially mediate the relationship between exercise and depression. (Wipfli, Landers, Nagoshi, & Ringenbach, 2011)

Depression

Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials comparing exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group. Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found. When these three trials were analyzed together, the effect size was not significant.

There is empirical evidence that exercise compares favourably to antidepressant medications as a first-line treatment for mild to moderate depression. Blumenthal and colleagues conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After four months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically significant difference between the groups. The medication group did have a faster response to treatment in the first four weeks, however. However, in a more recent study, the remission rates were also very similar (45-47%), while the rate in the placebo group was moderately, yet not statistically significantly, lower (31%).

Body Image

Exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms. Bodywork is related to body image. Bodywork allows us to become more aware of our bodies. It is not necessarily the aim that one builds muscles or achieves a body ideal, which changes as soon as the new magazine ad replaces the old one. But working on and with anything increases our awareness for it. This also applies to the body. By working with the body, we learn about the body. Out of the interaction with the body we get new meaningful information and vice versa. Our bodies are powerful information processing entities, and the information we put into it can bring about significant changes. Exercising is a form of interacting with the body and having the body interact with the world, which leads to a range of changes.

Body Image as a Problem

With a healthy sense of self and a positive body image to go with it, the psyche and the body can work together well and lead to an experience of happiness and contentment. Unfortunately, body image disturbance is an increasing problem in Western societies and is associated with several adverse mental health outcomes, including anorexia, bulimia, body dysmorphia, and depression. (Pimenta, Sánchez-Villegas, Bes-Rastrollo, Lpez, & Martínez-González, 2009)

Body image is, of course, a subjective perception, something that is built from information from the outside (such as a visual image from a mirror) and the inside (perceived needs, values, aspirations, expectations). Body image thus also depends on what we believe is essential and what we think we need, value and should aspire to. It depends on how we communicate and interact with ourselves and other people. (Haverkampf, 2010a, 2017a)

How one sees one’s body affects how one shapes one’s body in the future. It also influences how one feels about the body and, as a consequence, about oneself. Pimenta and colleagues studied the association between body image disturbance and the incidence of depression in 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for four years on average (the SUN study). The difference between BMI and body size perception was considered as a proxy of body image disturbance. Men who underestimated their body size were much more likely to be overweight and obese, whereas women who overestimated their body size were much more likely to be underweight. (Pimenta et al., 2009) However, the authors found no association between body image disturbance and subsequent depression.

Different population may place different emphases on different body attributes. Body fat may, for example, play a greater role in one population than in another, which is probably influenced to a large extent by socialization and communication with others. A study that looked at muscle dissatisfaction, body fat, and height dissatisfaction as predictors of signs of psychological distress, such as depression, eating restraint, eating concerns, and social sensitivity) in a community sample of 228 gay men found that body fat dissatisfaction was predictive of all four distress signs (controlling for muscle dissatisfaction). Conversely, muscle dissatisfaction was only associated with social sensitivity, while height dissatisfaction failed to significantly predict any of the criterion variables for distress. (Blashill, 2010) Another study found that women were more likely to engage in indoor tanning and perceived greater susceptibility to photoaging than men. Body image and depression were found to be associated with tanning behaviors and attitudes. (Gillen & Markey, 2012) Since preferred skin tone, and the behaviors to achieve it, has changed significantly throughout the ages, from very light in past centuries to suntanned in the 1970s and 1980s, social trends must play a significant role. Identifying how one takes in outside preferences and makes them one’s own is an important step in identifying more closely the own needs, values and aspirations, which has a direct effect on quality of life and mental health (Haverkampf, 2010b, 2017a).

Mood plays a large role in how one perceives one’s body. If one sees things more negatively overall, this can also affect one’s view of the own body. Joiner and colleagues examined the relationship between body dissatisfaction, depression, and bulimia in 119 female participants and found that depressed symptoms, but not whether the individual was bulimic, were associated with body dissatisfaction. (Joiner, Wonderlich, Metalsky, & Schmidt, 1995) It is thus important to keep in mind that aside from the effect of variations of the body on mood, the latter does have a significant effect on how we perceive the former. A significant aspect of how depression reduces the activity radius and the quality of life is through a distorted perception of the body.

Obesity

There is a relatively close link between obesity and depression, although it is unclear what is the cause and what the effect. Depression may cause obesity, for example through changing eating patterns or reduced physical activity. But it is also possible that obesity may cause depression through an even more negatively perceived body image, which is a result from an interaction between the obesity and experienced social norms and interactions. The author has discussed possible etiologic factors from a communication perspective elsewhere (Haverkampf, 2017b). In any case, it is easy to see how a vicious cycle can form at the intersection between the psychological and the physical. Breaking that cycle requires awareness for an individual’s internal and external communication.

That internal or external communication dynamics may play a significant role could explain why being ‘overweight’, but not the extremes of being underweight or severely overweight, is most highly correlated with depression. De Wit and colleagues showed in their study a significant U-shaped trend in the association between BMI and depression. (De Wit, Van Straten, Van Herten, Penninx, & Cuijpers, 2009) Externally, the social context seems to play a role. Xie and colleagues investigated in a prospective study the associations between overweight and depressive symptoms in Asian and Hispanic adolescents. Significant mediation effect was found only in Asian girls and girls with high acculturation. Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms. (Xie et al., 2010)

On the other hand, there is data which shows an independence from social factors and current comorbidities. Zhao and colleagues examined the associations of depression and anxiety with BMI after taking into consideration obesity-related comorbidities and other psychosocial or lifestyle factors. They analyzed the data collected from 177 047 adults in the US. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5), in women who were overweight (BMI:25–<30) or obese (BMI⩾30), and in men who were severely obese (BMI⩾40) than in those with a normal BMI. Compared with men with a normal BMI, severely obese men were significantly more likely to have current depression or lifetime diagnosed depression and anxiety. Underweight men were also significantly more likely to have lifetime diagnosed depression. Overweight or obese women were significantly more likely than women with a normal BMI to have all three psychiatric disorders. (Zhao et al., 2009)

Breast Cancer

A condition that threatens the body’s integrity also tends to have a psychological effect. If the condition represents a serious threat, fear and anxiety are normal reactions to it. In one study with female survivors of breast cancer of all ages, 56% of the participants had scores that would correlate with potential depression (Begovic-Juhant, Chmielewski, Iwuagwu, & Chapman, 2012). The majority of women felt less attractive and less feminine. Low body image, attractiveness, and femininity positively correlated with depression and negatively with overall quality of life. (Begovic-Juhant et al., 2012) However, this may also provide an approach for ameliorating the depression through work on body image and the self-perception of attractiveness and femininity. Much of this could involve work with communication (Haverkampf, 2017a).

The body and the mind are inseparable. If the integrity of one is in danger, that will reflect of the sense of wholeness of the other. Lasry and colleagues investigated the psychological and social adjustment following total and partial mastectomy. Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed a surprising rise in depressive symptoms, which could be related to an underestimated anxiety they experience. (Lasry et al., 1987)

Exercise as an Adjunct to Medication

Exercise has also been shown to improve depressive symptoms when added to medication. There seems to be an added benefit beyond the direct effect of the antidepressant. In one study, exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone. Unlike its benefit as an adjunct to antidepressant medications, exercise in addition to cognitive therapy was found not to be more beneficial than either one by itself. (Ströhle, 2009)

Techniques

Many types of bodywork exist, and several are generally assumed to maintain and improve overall health and raise the quality of life. Important is as already mentioned above, aside from the physical exercise, the greater awareness and the better more meaningful information about the body and how it interacts with the psyche and the outside world. However, there is still far less knowledge of movement-based treatments focusing on body awareness than medication or psychotherapeutic approaches.

While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise may not be as important as having the physical activity reach a sufficient intensity. For example, both running and weightlifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms.

Basic Body Awareness Therapy (BBAT)

Danielsson and Rosberg explored the experiences of basic body awareness therapy (BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinical trial. The participants’ experiences were essentially grasped as a process of

  • (Danielsson & Rosberg, 2015)

Five constituents of this meaning were described (Danielsson & Rosberg, 2015):

The authors conclude that the process of enhanced perceptual openness challenges the numbness experienced in depression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear. (Danielsson & Rosberg, 2015)

Pilates

Mokhtari and colleagues investigated the efficiency of 12-week Pilates exercises on depression and balance associated with falling in thirty elderly participants. The Pilates exercises decreased depression and improved the balance related to falling in participants. (Mokhtari, Nezakatalhossaini, & Esfarjani, 2013)

Body Psychotherapy (BPT)

Body Psychotherapy (BPT) may be an effective treatment option for patients with chronic depression. Rohricht and colleagues studied the effectiveness of BPT in patients with chronic depression. Patients with chronic depressive syndromes and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7). (Rohricht, Papadopoulos, & Priebe, 2013)

Mindfulness-Based Cognitive Therapy (MBCT) pursues the development of a heightened awareness of one’s body, and its effectiveness has been shown in several empirical studies. Research has focused on the interactions between bodily, cognitive, and emotional processes. Michalak and colleagues argue that considering embodied processes might be a useful perspective for research on the etiology of depression and for mechanisms of action in MBCT. (Michalak, Burg, & Heidenreich, 2012)

Tai Chi

Tai Chi has also been explored in its effectiveness against mental health conditions. It has soft movements, slower speeds, and is relatively easy to learn. The posture of high or low and the amount of exercise can be different according to individual physical fitness. It can meet the needs of different ages and physical fitness. Data from a small study with a single-case design suggests that the intervention had the strongest effect on the participant who presented with hyperactivity and heightened anxiety. (Baron & Faubert, 2005)

Yoga

Field and colleagues compared the effects of yoga (physical activity) versus social support (verbal activity) on prenatal and postpartum depression. Ninety-two prenatally depressed women were randomly assigned to a yoga or a social support control group at 22 weeks gestation. The yoga group participated in a 20-min group session (only physical poses) once per week for 12 weeks. The social support group (a leaderless discussion group) met on the same schedule. At the end of the first and last sessions the yoga group reported less depression, anxiety, anger, back and leg pain as compared to the social support group. At the end of the last session the yoga group and the support group did not differ. They both had lower depression, anxiety, and anger scores and improved relationship scores. In addition, cortisol levels decreased for both groups following each session. Estriol and progesterone levels decreased after the last session. At the postpartum follow-up assessment depression and anxiety levels were lower for both groups. (Field, Diego, Delgado, & Medina, 2013)

Exercise Dose

A dose-response effect with exercise in the treatment for depression has been noted. In one study, high-intensity weight training was more effective than low-intensity weight training in treating depression. Low-intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group.

Aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD of mild to moderate severity. Dunn and colleagues studied whether exercise is an efficient treatment for mild to moderate major depressive disorder (MDD), and the dose-response relation of exercise and reduction in depressive symptoms. Participants were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure and frequency or to exercise placebo control. A 17.5-kcal/kg/week dose is consistent with public health recommendations for physical activity. The main effect of energy expenditure in reducing Hamilton Rating Scale for Depression (HRSD17) scores at 12 weeks was significant. Adjusted mean HRSD17 scores at 12 weeks were reduced 47% from baseline for the 17.5-kcal/kg/week dose, compared with 30% for a lower dose and 29% for control. There was no main effect of exercise frequency at 12 weeks. (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005)

Exercise and Anxiety

Compared to the wide range of research on the positive effects of exercise on depression, anxiety disorders have been less frequently studied. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy.

In general, exercise does appear to be effective in reducing symptoms associated with anxiety. Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise.

In treating anxiety, exercise has been shown to alleviate anxious feelings. While useful in treatment, exercise does not seem to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier.

In another study, the effects of a Feldenkrais® Awareness Through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period. Analysis of variance showed that anxiety scores for all groups varied significantly over time and, specifically, that participants reported lower scores at the completion of the fourth intervention. Further, compared to the control group, females in the Feldenkrais® and relaxation groups reported significantly lower anxiety scores on completion as compared to the beginning of the fourth session, and this reduction was maintained one day later. (Kolt & McConville, 2000)

Anxiety Sensitivity

Exercising at 70%–90% of maximum heart rate for 20 minutes three times a week seems to reduce anxiety sensitivity significantly (Carek, Laibstain, & Carek, 2011). Self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program (Carek et al., 2011). In a study by Cox and colleagues, the most substantial reduction in state anxiety occurred 90 minutes following 20 minutes of aerobic exercise at 80% of maximal oxygen uptake (Cox, Thomas, Hinton, & Donahue, 2004).

Body Dysmorphic Disorder: OCD

The relationship between obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD‐spectrum disorder or even a type of OCD. There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. (Lochner & Stein, 2006)

Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with an imagined or slight defect in appearance, with depression as its most frequent comorbid condition. (Nierenberg et al., 2002)

BDD is frequently comorbid with major depression, is associated with an earlier age of onset of depression and longer duration of depressive episodes, and is found more frequently with atypical than non-atypical depression. Nierenberg and colleagues evaluated the rate of BDD in a cohort of consecutive outpatients with typical and atypical major depressive disorder in 350 outpatient participants. Twenty-eight (8.0%) subjects had a lifetime history of BDD and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier age of onset of depression and longer duration of the current episode, but not a greater number of depressive episodes or greater severity of depression. Subjects with and without BDD were similar with respect to age, gender, and marital status. There was a higher rate of lifetime and current BDD in subjects with atypical depression than in those with non-atypical depression. Subjects with BDD also had higher rates of social phobia, any eating disorder, and any somatoform disorder but not OCD. They also had higher rates of avoidant, histrionic, and dependent personality disorders. (Nierenberg et al., 2002)

OCD and BDD do not significantly differ on many variables but did have some clinically important differences. In one study, the comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity.

Lochner and Stein conducted a computerized literature search (MEDLINE: 1964–2005) to collect studies addressing different dimensions on which the OCSDs lie. Their cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms:

  • “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette’s disorder),
  • “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and
  • “Somatic” (including body dysmorphic disorder and hypochondriasis).

It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders. (Lochner & Stein, 2006)

It has been argued that body-focused repetitive behavior disorders (e.g., trichotillomania and skin-picking disorder) should be included within the obsessive-compulsive and related disorders category, as this is how most clinicians see these behaviors, and as this may optimize clinical utility. The descriptions of these disorders should largely mirror those in DSM-5, given the evidence from recent field surveys. (Stein & Bouwer, 1997)

Hypochondriasis

The symptoms of HC overlap to an extent with certain anxiety disorders, such as panic disorder and OCD. The results of a study using discriminant function analysis indicated that whereas individuals with hypochondriasis experience panic attacks, obsessions, and compulsions, these symptoms are markedly less pronounced than among those with panic disorder and OCD. Conversely, overlaps were found in terms of cognitive biases, with hypochondriasis patients demonstrating elevated levels of intolerance of uncertainty, body vigilance, and fear of cardiovascular symptoms. (Deacon & Abramowitz, 2008)

Risks

While the Center for Disease Control and Prevention and the American College of Sports Medicine recommend that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably) all days of the week, physical activity and exercise have risks that need to be considered. The most common risk of physical activity in adults is musculoskeletal injury. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports.

Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease.

Prevention

Reduced incidence rates of depression and (some) anxiety disorders in exercising subjects raise the question whether exercise may be used in the prevention of some mental disorders. A review of studies showed a bidirectional relationship between physical activity, exercise and adolescent mental health (Pascoe & Parker, 2019). The results suggested that physical activity and exercise programs designed to increase the level of activity in young people should be implemented to be attractive and achievable to young people that may have poor psychological health (Pascoe & Parker, 2019). Another study found that participating in diverse leisure activities and longer exercise time decreases older adults’ risk of having depression. Additionally, the results confirmed that depression is positively correlated with chronic diseases (Lee, Yu, Wu, & Pan, 2018). On the other hand, data from the Netherlands Mental Health Survey and Incidence Study did not find evidence for a dose–response relationship between exercise levels and mental health. Among those with mental disorder at baseline, exercise participants were more likely to recover from their illness compared to their counterparts who did not take exercise, but the authors pointed out that it remains uncertain whether this association truly reflects a causal effect of exercise (Ten Have, de Graaf, & Monshouwer, 2011). In a 2010 meta-review, an ssociation between physical activity and mental health in young people was evident, but research designs were described as often weak and effects small to moderate. Evidence showed small but consistent associations between sedentary screen time and poorer mental health (Biddle & Asare, 2011). In another study involving 42 undergraduates, vigorous exercise had mental health benefits beyond moderate physical activity, was associated with less stress, pain, insomnia and depression, more favorable objective sleep patterns, and fewer mental health problems if the individual was exposed to high stress (Gerber et al., 2014).

Conclusion

Depression and anxiety disorders are some of the most prevalent neurological disorders with close to one in five of adults demonstrating symptoms. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. (Phillips et al., 2007) The balance seems to be important. The term ‘exercise addition’ has been coined for another extreme, in which an individual experiences a need to engage in excessive exercise, has the potential to have adverse effects on both physical and mental health (Berczik et al., 2012).


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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CBT and Psychodynamic Psychotherapy

CBT-and-Psychodynamic-Psychotherapy-Christian-Jonathan-Haverkampf-2-psychotherapy-series

CBT and Psychodynamic Psychotherapy

Christian Jonathan Haverkampf, M.D.

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy, apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Keywords: CBT, psychodynamic psychotherapy, Communication-Focused Therapy, CFT, communication, psychotherapy, psychiatry

Table of Contents

Introduction. 3

Philosophical Differences. 3

Practical Differences. 4

Example: Obsessive-Compulsive Disorder (OCD) 5

Example: Depression. 6

Into the Future. 7

References. 9

Introduction

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy (see Lambert and Bergin, 1994), apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ (Breuer et al, 2000)  in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Philosophical Differences

The late nineteenth century with new discoveries in biological medicine and neurology and the emergence of Darwinian evolution provided the background for psychoanalysis. Psychoanalysis regards the mind as a complex yet structured system that produces and is affected by communication and meaningful information, not unlike individual cells in an organism. The patient’s free associations  are reflected upon by patient and analyst to explore and resolve intrapsychic conflicts and their defences, which cause ‘neurotic’ symptoms, such as anxiety, OCD, depression. Symptoms contain not only hints of repressed feelings and emotions, but also information about the patient’s authentic wishes and desires for individual growth.

CBT delivers a more action-oriented and problem-focused approach, in which treatment plans and goals are formulated without a prior analysis of the meaning of the symptoms.  CBT goes back to a merger of the behaviourism based on studies on conditioning and learning  and studies into cognitive processes by students of Freud , who believed cognitive processes to be closer to consciousness than their mentor. CBT focuses on an understanding of the mechanisms of present thoughts and behaviours rather than their pathogenesis. Both, however, teach their patients to become experts in their respective skills.

In psychodynamic theory, the development stages in childhood play an important role,  as do other past experiences, which are largely organised around interpersonal relations. In CBT, the focus is on conscious processes and the present. Psychoanalysis assumes that communication phenomena  between therapist and patient allow insight into partly unconscious intrapsychic processes, which are organised in a structured system (such as the tri-partite model of ego, superego and id) .

From a CBT perspective, distorted thought processes and maladaptive behaviours are direct causes of mental health symptoms (Hollon and Beck, 1994),  in psychodynamic theory they are ‘only’ symptoms and not to be confused with the underlying causes.  In CBT, logic, for example in the form of the Socratic dialogue, can be used to identify and discard false beliefs that cause unwanted thoughts and emotions (Beck at al, 1979). Psychodynamic therapy enables reason (the ego) to break down the defences, which protect from underlying conflicts.

In CBT, unhelpful thought patterns are made clear in the beginning (assessment phase), which, however, requires a norm  of ‘helpful thinking’ (Fancher, 1995). In psychodynamic psychotherapy, what is ‘helpful’ depends on the individual and has to be worked out in the exploratory process.

Both therapeutic approaches are growing organically, though unfortunately with less than optimal cross fertilisation. Emotional, motivational and relational aspects have been added to CBT.  Neural networks and neural computation models are used in psychodynamic research (Peled, 2008), as well as in the cognitive sciences which underlie CBT. The neurosciences , infant research , neurobiology , attachment psychology and other fields have contributed significantly to psychodynamic theory.

Practical Differences

Treatment in CBT is usually shorter, often below twenty sessions, and with longer inter-session intervals.   There is an evidence-based short-term psychodynamic psychotherapy (STPP) which, however, has in a meta-analysis shown to be “significantly” less effective than the longer version (LTPP) (Leichsenring and Rabung (2008).

Both therapies transfer skills. In CBT the therapist is “very active” (Hofmann, 2011) and the approach is highly structured (Gatchel, 2008) , often with homework and including an initial assessment, education on the course of therapy (Hofmann, 2011), a reconceptualization of the problem, skills acquisition, skills training, generalisation and maintenance, and another assessment. In psychodynamic psychotherapy, patients learn in the therapist-patient interaction to gain insight into their unconscious dynamics and to become their own analysts.

Since CBT assigns lower priority to the specific thought content and the communication dynamics between patient and therapist and defines problems more narrowly, psychoeducation and ‘manualisation’  are easier to integrate, particularly in clearly defined situations, such as drug addiction (Carroll, 1998) . CBT also lends itself better to conduct therapy over a distance (Weiss et al, 2012; Himle et al., 2006) , including the use of e-mail therapy (Vernmark et al, 2010). Computer programmes (CCBT) can make therapy available to millions of previously underserved populations. 

Both, CBT and psychodynamic psychotherapy have proven their effectiveness in numerous studies and large meta-analyses.  However, direct comparisons of the effectiveness of CBT and psychodynamic psychotherapy can be flawed by design if the two therapies are complementary and conceptually related. Bram and Björgvinsson (2004), for example, have successfully integrated exposure-response prevention into their psychodynamic therapies. Measuring success in completed therapy phases seems equally problematic, but is still often used.

CBT is likely to deliver quicker results in motivated patients with clearly defined symptoms, low resistance levels and relatively intact personality structures (with the exception of borderline personality disorder and DBT). Psychodynamic psychotherapy may have advantages in dealing directly with personality disorders,  which are traditionally derived from psychodynamic models.

Leichsenring and Leibling (2003) demonstrated in a meta-analysis a better long-time effectiveness of psychodynamic psychotherapy than CBT, while CBT on its own has shown to prevent relapses in the long-run (Driessen et al, 2013). Much of the apparent diversity in opinion may depend on the specific diagnosis in question.

CBT may have higher drop-out rates (Cuijpers et al, 2008; Whittal et al, 1999). Motivation seems more external in CBT (see Haddock et al, 2012) than in psychodynamic psychotherapy with its emphasis on the therapeutic relationship  and the integration of the more recent motivational systems research (see Lichtenberg at al, 2016). Adding these psychodynamic elements in CBT therapies may lead to better outcomes.

Example: Obsessive-Compulsive Disorder (OCD)

In psychodynamic theory, the anxiety underlying OCD is a result of conflicting dynamics (including emotions), often with a strong relationship component. A conflict may arise in an unstable relationship to an important other, such as a primary caretaker in early childhood, as the feelings of love for the idealised mental representation of the other (longing for attachment) and the frustration, sadness and/or abandonment about the reality of this person’s unpredictability or unreliability cannot be resolved by the child.  Higher levels of aggression and distrust in other people have indeed been found in OCD (Moritz, 2011), and infant research has demonstrated how the interaction between primary caretaker and child can affect the child’s evolving sense of self and feeling of secure attachment . Obsessive thoughts and compulsive rituals are aimed at temporary relief from the heightened anxiety in present situations which trigger the situational and associated emotional memory systems of previous situations . Awareness of the underlying emotional conflict, which manifests through the symptoms, helps the patient to recognise, identify the ‘free-floating’ anxiety in the past experience, which reduces the anxiety from experienced emotional uncertainty and the OCD symptoms in the present.

                The cognitive-affective schemata of newer developments in psychodynamic theory  have considerable overlap with CBT concepts of the effect of learned cognitive schemata. From a CBT perspective, obsessive thoughts are otherwise ‘normal’  negative thoughts which may be misinterpreted as personally significant (Rachman, 1997) or as a potentially dangerous situation for which the patient feels responsible (Salkovskis, 1985), response patterns which are largely learned (Taylor and Jang, 2011). Compulsive rituals are efforts to control these intrusive thoughts. After performing the rituals, individuals usually report a temporary decrease in their obsessional distress (Rachman and Hodgson, 1980), which negatively reinforces these behaviours, a mechanism similar to CBT models on addiction.

Exposure and Response Prevention (ERP)  tries to break this cycle of negative reinforcement, in which the patient is repeatedly exposed to an anxiety-provoking thought or situation stimulus, but the self-calming ritual is reduced or suppressed. The anxiety may increase in the beginning, but then reach a peak and fade away.  Exposure necessarily leads to an involvement of the patient’s emotional memory and an emotional processing of the anxiety (Foa and Kozak, 1986), which seems a point where CBT and psychodynamic psychotherapy again intersect. Basically, both approaches try to give patients a greater sense of positive control over their lives.

Example: Depression

                Freud considered the internalisation of object loss as a normal part of life, and depression as a reaction formation in the face of a particularly severe super-ego , which holds in check our basic desires and wishes (the ‘id’) with the help of conscious cognitive functions (reason, the ‘ego’). In CBT, the super-ego could be compared to the messages we learn over time and the believes we construct of how we ‘should’ live our lives. And similar to the concept of limited cognitive resources in CBT, the rational ‘ego’ function in psychodynamic theory may get overwhelmed in stressful and traumatic situations and become unable to reconcile the super-ego and the id, leaving an unresolved emotional conflict,  which the ego (reason) needs to defend against. Loss and the emotions associated with this conflict (such as anger, sadness or helplessness) are important themes. Anxiety and avoidance have been shown to be greater in people with more insecure attachment (Bateman & Fonagy, 2012),  who are often more dependent and self-criticising, eliciting responses from others that confirm their fears of rejection and abandonment (see Blatt, 1974; Blatt, 1992). The negative emotions then lead to a ‘withdrawal’ from one’s own emotions (repression), reminiscent of learned helplessness in CBT. Awareness of the underlying dynamics and their origin in the past, helps the patient to understand and integrate them in the present.

                In CBT, thoughts, behaviours and feelings are directly interrelated, which can lead to a circularity that is in psychodynamic theory ‘impossible’. Negative thoughts can lead to depressed feelings, which again lead to negative thoughts and ‘depressed’ behaviour, such as social withdrawal, reinforcing the depression. Maladaptive cognitive patterns, such as negative thinking about oneself and one’s experiences (McGinn, 2000), increase the vulnerability for depression.   In learned helplessness, for example, the sense of low self-efficacy brings about behaviour that just reaffirms the low self-efficacy.

In the cognitive aspect of CBT, a person learns to recognize and turn negative automatic thoughts into realistic  beliefs. More realistic beliefs lead to more adaptive thoughts and less depressed feelings. Patients are taught to deconstruct problems into the actual situation, and the thoughts, feelings and behaviours that occur before, during and after the situation, an external correlate to the internal deconstructive process in psychodynamic psychotherapy. In Mindfulness CBT (MCBT)  the emphasis is on experiencing one’s thoughts as mental events rather than interpreting them as representations of oneself or reality. This detachment from negative thoughts and feelings is also useful in preventing relapse (Teasdale, 1999).

Into the Future

The aim of psychotherapy is not merely to eliminate suffering (WHO, 1946), but to help patients develop as humans. The primary tool is communication, in CBT to provide information that generates change and in psychodynamic psychotherapy to reveal the information that brings about change.  There are synergistic effects from using both. Zipfel et al (2014) showed in a large sample of anorexic patients, that CBT was associated with weight gain, while psychodynamic psychotherapy with lower relapse rates at the 12-month follow-up. McFall and Wollersheim (1979) in an early study successfully used a combination of CBT and psychodynamic psychotherapy in anxiety . Given the widely-perceived need for multimodal approaches , it is difficult to comprehend that this should not apply to the most important therapeutic models we have. In ancient Greece, knowing oneself (γνῶθι σεαυτόν, “know thyself”) and the process of the Socratic dialogue were inextricably linked. Psychodynamic psychotherapy and CBT should be viewed as complementary rather than substitutes.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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