Integrating Evidence-Based Approach in Mental Health Consultation

Part IV: Case Applications Timothy R. Jennings, M.D. DLFAPA Medical Direct, Honey Lake Clinic Past-President Southern Psychiatric Association Past-President Tennessee Psychiatric Association Author: Could It Be This Simple? The God Shaped Brain The Remedy New Testament Paraphrase The Remedy of the Lord in Song: The Psalms The God-Shaped Heart The Aging Brain: Proven Steps to Prevent Dementia and Sharpen Your Mind www.comeandreason.com Slides at: comeandreason.com/AACC

Review www.comeandreason.com

INTEGRATIVE EVIDENCE-BASED APPROACH

Design Law 1. Integrative Evidence-Based Approach 2. Law of Love 3. Law of Liberty 4. Law of Truth 5. The Law of Sewing and Reaping 6. Law of Worship 7. The Law of Exertion www.comeandreason.com

Overview Present a case Ask what else you would like to know Formulate a conceptualization of the patient s presentation Identify which design laws were being violated Formulate an intervention plan www.comeandreason.com

Sergeant Jones 34 y/o AA male Tank Commander during Desert Storm Presents 4 years later Nightmares/flashback Sleep disturbance Irritability Anxiety Relationship conflicts Impaired concentration Depression SI www.comeandreason.com

What Do You Want to Know? No alcohol or illegal drug use On no meds No medical problems www.comeandreason.com

Further History Strong believer in God, public testimony NODS failed Commander cannibalized his radio Went into battle deaf and blind Unit entered battle Felt like abandoned by country and God and left like a helpless lamb to be slaughtered How do you conceptualize his situation? www.comeandreason.com

Conceptualization Amygdala activated Events didn t fit his framework and he believed a lie - Salience network was disrupted No DLPFC involved to calm amygdala Increased OFC VMPFC activity with ruminating loop Activation of inflammatory cascade Depression, altered brain structure DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? What Design laws are being violated? Law of truth and law of worship violated What intervention? It sounds like Daniel and the lion s den Truth restores salience network, calmed amygdala resolved MDE DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Jeanne 43 y/o WF who presented with long history of anxiety, insecurity, and fear of failure Tension with husband and children She was committed Christian, who aggressively did everything she believed God wanted her to do but rarely, if ever, experienced any joy Sleep disturbance, tension, worry, inability to relax, classic GAD symptoms www.comeandreason.com

What Further History? No alcohol/drugs No psych meds in past Negative family history After a year of working together she finally disclosed she became pregnant shortly after marriage, but it ended in a miscarriage But prior to marriage she had gotten pregnant and had an abortion She believed that God punished her for the abortion by causing the miscarriage (killing her baby). www.comeandreason.com

Conceptualization Pregnancy out of wedlock fear Abortion internalized as doing wrong resulting in guilt, compounding fear Reaction more vigilance in doing good, increased religiosity, scrupulousness and rule- keeping which offset the guilt/fear Miscarriage interpreted as punishment from God Disrupted salience network, chronic ruminations, anxiety, depression www.comeandreason.com

What Intervention and Why? Therapy to resolve the distortions in her belief system, which will restore the salience network and calm amygdala The primary distortion is about God why must this be resolved? www.comeandreason.com

Katie 27 y/o MWF with dx of Schizoaffective d/o HX recurrent psychosis when stressed with several previous psych hospitalizations Has been stable for 5 years on current meds (quetiapine, mirtazapine, lamotrigine, alprazolam) living independently, no psychosis, no hospitalizations Presents today with increasing anxiety, panic, sleep disturbance and ruminations about demons www.comeandreason.com

What Else Do You Want to Know? No use of alcohol or illegal substances No change in financial or marital stressors No traumas No health-related changes www.comeandreason.com

What Changed? She began watching 4-6 hours of horror movies per day www.comeandreason.com

What Law was Being Violated? Law of worship by beholding we become changed Her TV watching was upregulating amygdala, causing increased fear-based thinking patterns, with elevations in inflammatory cascades, and neurovegetative changes www.comeandreason.com

What Intervention? Instructed to stop all horror movies In two weeks and she was back to baseline www.comeandreason.com

Elle 20 y/o SWF presents with anxiety, depression, cutting, eating issues, feeling fat (5 3 108#) No history of physical or sexual abuse No history of alcohol/drug/tobacco use What else do you want to know? www.comeandreason.com

Elle Raised in conservative Christian home, many rules, little affection Feels inadequate, nothing good enough, feels like failure, fears rejection, hard time saying no What else? www.comeandreason.com

Elle What does her feeling fat at 108 tell you? She is believing a lie why? One feeling masquerades as another Ask: What does it feel like to feel fat? Lazy, shameful, guilty What do you ask? What do you feel guilty about? She had been stealing from her employer www.comeandreason.com

Conceptualization What law was being violated? Violate law of Love & Truth amygdala activated Denial to avoid guilt disrupted salience network No DLPFC (truth) involved to calm amygdala Increased OFC VMPFC activity with ruminating loop Activation of inflammatory cascade Depression, anxiety, negative ruminations Projection to body, avoid guilt by not eating DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Truth restored salience network, calmed amygdala Repentance and restoration calmed OFC/VMPFC and restored salience network, resolved guilt, calmed amygdala Anxiety and body concerns remitted DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Jim 29 y/o WM with 14-year history of panic Increased HR, SOB, Tremulousness, Hot Flash, Nausea, Vomiting, Fear of Dying, Social Isolation Came to Psychiatrist to continue meds Effexor XR 225, Buspar 15 TID, Ativan 1mg TID Failed Prozac, Paxil, Zoloft, Celexa, Lexapro No Substance abuse history Current status panic 1-2 per week, stays in safe zone What else do you want to know? www.comeandreason.com

Jim At age 14 tornado, saw the damage and said, I feared for my life then began having panic with thunderstorms, which soon escalated to panic for no reason Now lives in constant fear of panic, is hyper-vigilant watching for anything that signals impending panic Stays within a couple miles of his home Volunteer fireman, who can t ride the truck, but when drives self to scene and helping others panic remits www.comeandreason.com

Conceptualization Initial threat caused activation of amygdala What law was violated? Violation of law of truth and formed belief that all storms are life threatening inciting fear disrupting salience network More panic Formed belief that panic attacks were to be feared Developed hyper-vigilance to avoid panic, which became a reinforcing loop DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Truth-all storms are not harmful & panic attacks are not harmful restored salience network, calmed amygdala Identify situational triggers (drowning, trapped) Altruism Activates ACC/calms amygdala Meditation Activates ACC/calms amygdala DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Jillyn 19 y/o SWF Presents with complaints and previous diagnosis of GAD and Panic which began one year ago when started college Symptoms classic GAD, worrying all the time, and panic neuroveg review On escitalopram 20mg per day Previously treated with fluoxetine, sertraline, citalopram Not improved, continued panic www.comeandreason.com

Jillyn What else do you want to know? No illegal substance use, no alcohol, no tobacco Negative family history No other previous psychiatric diagnosis www.comeandreason.com

Jillyn Difficulty organizing, planning, prioritizing Easily distracted Must reread material many times Cannot read with conversations or TV on Misplaces things Forgetful Makes careless mistakes www.comeandreason.com

Conceptualization Physiological brain problem - Untreated ADHD Lived at home mother acted as executor Moved to college cannot organize, plan, prioritize etc. Falls behind, gets overwhelmed, feels pressure, begins to worry, ruminate, panic Gets misdiagnosed Put on SSRI Worsens DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Taper and stop SSRI Initiate stimulant or other ADHD med Initiate omega 3 FAs Initiate L-methyl folate Reassess Counseling re: coping strategies, resolve any distorted self-image DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Lynda 36 y/o MWF Referred for panic and depression Presents with classic panic episodes and Neurovegetative symptoms of depression Hopeless and discouraged 3 previous psych hospitalizations for suicidality and disorganized behavior History of many psych meds, limited benefit Her demeanor is distraught, tearful and distressed No substance use problems www.comeandreason.com

Lynda What else do you want to know? Married controlling and domineering husband He monitored her activities Only gave her money to spend as he approved He required receipts even for groceries She could not use the phone without his permission Forbidden from talking with friends or really forming outside relationships He criticized her ideas if they were different than his He frequently accused her of being an unloving wife www.comeandreason.com

Conceptualization What law is violated? Law of Liberty violated Love damaged Fear incited Salience network disrupted as she refuses to set healthy boundary and submits to unreasonable control Ruminating loops happen Inflammatory cascades Panic and depression DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Meds for stabilization Education on Law of Liberty Must choose to think for self Therapy to establish healthy thinking, boundaries, and learn reflection Reconnects salience network, calms amygdala DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Tara 34 y/o MWF Presents with panic, GAD and emerging depression, feeling as if falling apart and unable to cope with life This all started when notice one pubic hair on 6 y/o daughter No substance abuse history No prior psychiatric contacts or treatments What else do you want to know? www.comeandreason.com

Tara Identifies herself as bisexual states was lesbian for many years, but later became bisexual First romantic encounter was at age 14 with female roommate at Christian boarding school Because of this thought of self as lesbian In college had lesbian relationship with female roommate Later began having sexual relations with men, and changed her identity to bisexual and eventually married in late twenties and had a daughter www.comeandreason.com

Tara What else do you want to know? Father molested her from earliest memories until she moved out at 14 to go to boarding school The abuse was seductive and romantic i.e. he made it out to be a love relationship with daddy, made her feel special www.comeandreason.com

Conceptualization What law violated? Law of love and worship and then law of sowing and reaping reinforced Idealized father Altered boundaries, self, relationships, intimacy Came to believe healthy love included sex Thus if you love someone you have sex with them DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Meds for stabilization Never discussed sexual orientation directly Addressed finding self, establishing own identity, engaging her judgment Her 6 y/o daughter s pubic hair triggered decompensation as she feared for her daughter After 12 months therapy said, I ve never had an intimate relationship without sex DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? To which I said, What about us? Which changed her belief about self, she came in the next session and said Dr. Jennings, I m heterosexual. Her anxiety resolved as we worked through her trauma, forgiveness issues and she solidified her identity DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

Betty 81 y/o widowed WF presented with recent first episode of depression Primary complaint insomnia, but also impaired concentration Slower work performance, (still worked as part time teacher) Decreased appetite Poor energy and motivation www.comeandreason.com

What Else? No alcohol, tob, drugs No medical problems On no meds MMSE 30/30 Walks daily, vegetarian diet, believes in God, attends church weekly No new loss or life change www.comeandreason.com

Conceptualization What law violated? Laws of Health aging Loss of white matter connectivity, with biological brain change leading to late life depression DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala

What Intervention and Why? Medication Mirtazapine Unique mechanism Presynaptic autoreceptor antagonist (5HT & NE) H1 blocker 5HT3 antagonist Excellent response, depression remitted, tapered to 7.5mg QHS stable for 10 years DLPFC ACC VMPFC Orbital PFC Nucleus Accumbens Amygdala