Psychotherapy Overview

Primary or adjunctive treatment modality for psychiatric and behavioral disorders.
Combined Pharmacotherapy + Psychotherapy: Superior to monotherapy for moderate-to-severe MDD, persistent depressive disorder (dysthymia), panic disorder, and OCD.
Selection depends on dx, level of cognitive functioning, acute vs. chronic setting, and pt goals.

Cognitive Behavioral Therapy (CBT)

Core Mechanism:
- Identifies and modifies maladaptive thought patterns (cognitive distortions, automatic negative thoughts) and conditioned behaviors.
- Uses cognitive restructuring, behavioral experiments, and exposure techniques.
Key Indications:
- MDD: First-line monotherapy for mild-to-moderate; synergistic w/ SSRI/SNRI in severe.
- Insomnia: CBT for Insomnia (CBT-I) is first-line prior to hypnotic pharmacotherapy (sleep hygiene, stimulus control, sleep restriction).
- Anxiety Disorders: GAD, Panic Disorder, Social Anxiety Disorder (SAD).
- OCD: Includes Exposure and Response Prevention (ERP).
- Bulimia Nervosa: Psychotherapy of choice.
- Somatic Symptom Disorder & Illness Anxiety Disorder: First-line behavioral treatment.

Core Mechanism:
- Modification of CBT designed for severe emotional dysregulation.
- Focuses on 4 modules: Mindfulness, Distress tolerance, Emotion regulation, and Interpersonal effectiveness.
Key Indications:
- Borderline Personality Disorder (BPD): Gold standard; reduces parasuicidal behavior, deliberate self-harm (cutting), and ED visits.
- Chronic suicidality and severe emotional lability.
- Refractory bulimia nervosa or binge-eating disorder w/ comorbid cluster B traits.

Core Mechanism:
- Time-limited, structured therapy focusing on interpersonal context and social functioning.
- Targets 4 domains: Grief/complicated bereavement, role transitions (e.g., divorce, retirement), role disputes (conflicts w/ partner), and interpersonal deficits.
Key Indications:
- MDD: High efficacy, especially when depression is triggered by life events, relationship conflict, or major transitions.
- Postpartum depression.

Core Mechanism:
- Ego-syntonic support; does not probe unconscious conflicts or confront maladaptive behaviors aggressively.
- Bolsters existing defense mechanisms, offers reality testing, emotional validation, and advice.
Key Indications:
- Acute crises: Severe grief, recent catastrophic medical dx, acute adjustment issues.
- Low-functioning / Psychotic patients: Chronic schizophrenia maintenance to reinforce treatment adherence and daily functioning.
- Patients unable to tolerate the introspection or confrontation required in CBT/Psychodynamic therapy.

Core Mechanism:
- Explores unconscious conflicts, past childhood/developmental experiences, defense mechanisms, and relational patterns.
- Utilizes transference (pt projecting feelings about past figures onto therapist) and countertransference (therapist’s emotional reaction to pt).
Key Indications:
- Higher-functioning individuals w/ persistent relational difficulties, chronic dissatisfaction, or neurotic traits.
- Cluster C personality disorders (Avoidant, Dependent, OCPD).
- Requires capacity for introspection, psychological mindedness, and emotional stability (contraindicated in active psychosis).

Core Mechanism:
- Patient-centered, non-judgmental, directive approach to address ambivalence regarding behavior change.
- Emphasizes personal autonomy, assesses readiness to change (Prochaska Stages of Change), and rolls with resistance.
Key Indications:
- Substance Use Disorders (SUD): Alcohol, opioid, stimulant, and tobacco use.
- Treatment adherence issues (e.g., poorly controlled DM2, HTN medication non-compliance).

Exposure and Response Prevention (ERP):
- Mechanism: Prolonged exposure to obsession-provoking stimuli while refraining from performing the neutralizing compulsion until anxiety naturally decays.
- Key Indication: OCD (first-line psychotherapy; equivalent/additive to high-dose SSRI).
Systematic Desensitization:
- Mechanism: Graduated exposure combined with relaxation techniques (counter-conditioning).
- Key Indication: Specific Phobia (first-line therapy; benzos generally avoided).
Prolonged Exposure (PE) / Cognitive Processing Therapy (CPT):
- Mechanism: Narrative re-processing of traumatic memories and in vivo exposure to avoided safe trauma reminders.
- Key Indication: PTSD.
Eye Movement Desensitization and Reprocessing (EMDR):
- Alternating bilateral stimulation during trauma processing; alternative evidence-based option for PTSD.

Family-Focused Therapy / Family Therapy:
- Anorexia Nervosa (Adolescents): Maudsley model is the first-line intervention (parents control re-feeding).
- Schizophrenia: Family psychoeducation significantly reduces relapse/rehospitalization rates by lowering expressed emotion (EE) (hostility, over-involvement, criticism).
- Pediatric behavioral disorders (Conduct Disorder, ODD).
Biofeedback:
- Uses autonomic monitoring (electromyography, skin temperature, HR variability) to train voluntary physiological regulation.
- Indications: Tension-type headache, migraine prophylaxis, Raynaud phenomenon, pelvic floor dyssynergia (chronic constipation).
Group Therapy:
- Cost-effective, counteracts isolation, promotes universality.
- Indications: Substance abuse recovery (e.g., 12-step programs), bereavement, chronic illness support groups.

Clinical Presentation	Preferred Psychotherapy	Notes / Board Pearls
BPD w/ recurrent non-suicidal self-injury	DBT	Pharmacotherapy is adjunct only (atypical antipsychotics/SSRIs do not cure BPD).
OCD (contamination fears, hand-washing)	CBT w/ ERP	Combine w/ SSRI (sertraline, fluoxetine) if severe.
Chronic Insomnia	CBT-I	Prioritize over z-drugs/sedatives; incorporates stimulus control.
Adolescent w/ low BMI, Bradycardia, Lanugo	Family-Based Therapy	Maudsley approach; hospitalized if hemodynamically unstable.
Schizophrenia pt stable on AP, high home conflict	Family Therapy	Target is to decrease high expressed emotion.
Pt ambivalent about smoking cessation/alcohol use	Motivational Interviewing	Ask open-ended questions; explore pros/cons.
Severe fear of flying / heights / needles	Systematic Desensitization	Graded exposure is definitive; short-acting benzos only if infrequent/urgent.
MDD triggered by recent divorce/job loss	IPT or CBT	IPT specifically targets role transitions/interpersonal disputes.
High-functioning pt w/ recurring toxic relationships	Psychodynamic Therapy	Evaluates repetitive subconscious patterns and early attachments.

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