cognitive behavioral therapy an evidence based treatmentan ...€¦ · diagnosis and epidemiology...

Cognitive Behavioral Therapy an Evidence Based Treatmentan Evidence Based Treatment

for Parkinson’s Disease Psychosis

Henry A. Montero, PhD Candidate, M.Sc., LMHCFellow for Global Foundation for Development and

Democracy

Table Of Contents / IndexI t d tiI t d ti• Diagnosis and Epidemiology of Parkinson’s DiseaseIntroductionIntroduction

Parkinson’s DiseaseParkinson’s DiseaseCognitive Behavioral TherapyCognitive Behavioral Therapy• Psychotic Symptoms• Biological Psychosocial Vulnerability Model• Cognitive Behavioral Therapy for Parkinson’s Disease Psychosis

g pyg py

Scientific ImpactScientific ImpactScientific ImpactScientific ImpactLiterature ReviewLiterature ReviewTherapeutic ModelTherapeutic ModelAssessments and MeasuresAssessments and MeasuresF f TF f TFocus of TreatmentFocus of Treatment

• Research• Research Background

MethodologyMethodology

Help Individual with Parkinson’s Disease and Care GiversHelp Individual with Parkinson’s Disease and Care GiversDominican Cultural PracticeDominican Cultural PracticeConclusionConclusion

Introduction

Henry Montero TapiaHenry Montero Tapia

• Harold Abel School of Psychology Capella UniversityPh.D. CandidatePh.D. Candidate• Harold Abel School of Psychology - Capella University

• Manhattan College - Licensed in the State of New York, New Master of Science Master of Science

g ,Jersey

M C ll B i Ad i i t ti d C tBachelor of ArtsBachelor of Arts• Monroe College - Business Administration and Computer

Information Technology

Diagnosis and Epidemiology of Parkinson’s Disease

Parkinson’s Disease is a neurodegenerative movement disorder, affecting over six million people worldwide (Parkinson's Disease F d ti I 2014)

Parkinson’s Disease is a neurodegenerative movement disorder, affecting over six million people worldwide (Parkinson's Disease F d ti I 2014)Foundation, Inc., 2014). Foundation, Inc., 2014).

6 % of the Dominican population is 65 years old and older(The World Bank, 2014) 6 % of the Dominican population is 65 years old and older(The World Bank, 2014)

Dominican Republic has approximately six thousand citizens living with PD or another neurodengentetive conditionDominican Republic has approximately six thousand citizens living with PD or another neurodengentetive conditionwith PD or another neurodengentetive condition.(extrapolation by Castillo, 2014 )with PD or another neurodengentetive condition.(extrapolation by Castillo, 2014 )

Diagnosis and Epidemiology of Parkinson’s DiseaseThe pathological finding associated with PD is the degeneration of dopaminergic neuronsof the Pars Compacta of the Substantia Nigra leading to the depletion of dopamine in thestriatum (Factor & Weiner, 2007)

50-60% of the nigral

neurons are depleted

Symptoms for PD donot appear

80-85% of the dopamine substance of the stratum is lost

100%

Depleted Neurons

eu o s a e dep etednot appear until

the stratum is lost

100%

Dopamine Lost

20%

40%

60%

80%

20%

40%

60%

80%

0%Nigral Neurons

Wirdefeldt, Adami, Cole, Trichopoulos, & Mandel (2011)

0%Nigral Neurons

Parkinson’s Disease Diagnoses

Diagnosing a problem that cannot be diagnosed is a critical issue in PD Diagnosing a problem that cannot be diagnosed is a critical issue in PD

There are no biomarkers or specific neuroimaging findings for the diagnosis of

PD.

There are no biomarkers or specific neuroimaging findings for the diagnosis of

PD.

PD is determined based on criteria of Parkinsonian symptoms after a hypothetic-

deductive process is confirmed.

PD is determined based on criteria of Parkinsonian symptoms after a hypothetic-

deductive process is confirmed.ImpairedImpaired

The idiopathic condition of PD is the presence of two or more of the conjoint

symptoms:

The idiopathic condition of PD is the presence of two or more of the conjoint

symptoms:

Resting tremorsResting tremors Rigidity Rigidity Hyperki

nesiaHyperki

nesiaImpairedpostural reflexes

Impairedpostural reflexes

According to Braak, Ghebremedhin, Rub, Bratzke, & Del Tredici (2004)

Diagnosis and Epidemiology of Parkinson’s DiseaseDefinition

A clinical definition of PD is not defined, but the accepted definition is the presence of two or more cardinal motor symptoms including (bradykinesia) and a positive response to

Levodopa medication provide partial diagnoses of PD.

A clinical definition of PD is not defined, but the accepted definition is the presence of two or more cardinal motor symptoms including (bradykinesia) and a positive response to

Levodopa medication provide partial diagnoses of PD.

There is an error rate of approximately 25% of misdiagnosing PD with other diseases with similar characteristics and it can only be proven postmortem (Macphee & Stewart, 2007).There is an error rate of approximately 25% of misdiagnosing PD with other diseases with similar characteristics and it can only be proven postmortem (Macphee & Stewart, 2007).y p p ( p , )y p p ( p , )

Symptoms associated with PD are non-motor indicators that are common in early PD. Recognition of the combination of non motor and motor symptoms that can develop aids in

Symptoms associated with PD are non-motor indicators that are common in early PD. Recognition of the combination of non motor and motor symptoms that can develop aids inRecognition of the combination of non-motor and motor symptoms that can develop aids in

early detection and thus early intervention, which often results in a better quality of life. Recognition of the combination of non-motor and motor symptoms that can develop aids in

early detection and thus early intervention, which often results in a better quality of life.

Parkinson’s Disease PsychosisPsychosisPsychosis

Joseph Freidman (2011) stated PDP should be diagnosed

only after medical and environmental causes of

Joseph Freidman (2011) stated PDP should be diagnosed

only after medical and environmental causes ofonly after medical and environmental causes of

delirium/dementia have been eliminated or addressed.

Treatment with pharmacologic and psychotropic medication

only after medical and environmental causes of

delirium/dementia have been eliminated or addressed.

Treatment with pharmacologic and psychotropic medicationTreatment with pharmacologic and psychotropic medication

should be noted since implications exacerbate PD

(Fujimoto, 2009).

Treatment with pharmacologic and psychotropic medication

should be noted since implications exacerbate PD

(Fujimoto, 2009).

Parkinson’s Disease Psychosis

Consequently, elevated dopamine levels can trigger psychosis. For this reason, treatment often becomes a balancing act.

Consequently, elevated dopamine levels can trigger psychosis. For this reason, treatment often becomes a balancing act.

Parkinson’s Disease Psychosis (PDP)Parkinson’s Disease Psychosis (PDP)

gg

Prominence of visual hallucinationsProminence of visual hallucinations

Reduced quality of lifeReduced quality of life

The exact pathophysiology of PDP remains unknownThe exact pathophysiology of PDP remains unknownp p y gyp p y gy

Parkinson's disease patients do not generally tolerate classical antipsychotic drugs.

Cognitive Behavioral Therapy

CBT i h d f h f i i h l i hi bCBT i h d f h f i i h l i hi b

(CBT)(CBT)

CBT is a method of treatment that focuses on examining the relationships between thoughts, feelings and behaviors.

CBT is a method of treatment that focuses on examining the relationships between thoughts, feelings and behaviors.

CBT explores patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts,

CBT explores patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts,

CBT helps by modifying patterns of thinking to improve coping skills. People who pursue CBT can expect their therapist to be problem-focused, and goal-directed in addressing the

challenging symptoms

CBT helps by modifying patterns of thinking to improve coping skills. People who pursue CBT can expect their therapist to be problem-focused, and goal-directed in addressing the

challenging symptomschallenging symptoms.challenging symptoms.

Psychological/Physical Perspective

The individual is dealing with the gradual loss of abilities that accompanied by the progression of PD. In thiscapacity, the theoretical implication is based on Evidence Based Medicine (EBM) this practice delineates thedegree in which a neuro-degenerative disease can impact the emotional wellbeing of a PD patient.

According to Cochrane et al. (1989) from theepidemiological point of view EBM, can bedefined as

EBM does not specify an approach that canaccount for the understanding of the impact andconsequences of patient’s emotions/feelings,defined as consequences of patient s emotions/feelings,neither are there any opinions that can provide thepsychology community with criteria to work from.The researcher will add a variable to EBM

conditioncondition Treatment Treatment OutcomeOutcomeConditionEmotion

ConditionEmotion

Treatment Treatment OutcomeOutcome

The PD patient has a condition that produce an emotion thatwill be impacted by the treatment that will impact the outcome.

A (Condition) / Y (Emotion) + B (Treatment) = X (Outcome)• A (Condition) + B (Treatment) = X (Outcome)

Cognitive Behavior Therapy

• Actions• Behavior

• Observable

• Thoughts• Beliefs• Cognitions

Activitiesg

• Self-TalkCognitiveCognitive BehavioralBehavioral

• Biology• Feeling

PhysiologicalPhysiologicalEmotionalEmotional

Biology• Genetics

• Environmental

g• Mood• Emotions

Application of CBT

SIC Model Involves Educating and Helping Patients to Develop:SIC Model Involves Educating and Helping Patients to Develop:

Skills for modifying beliefsSkills for modifying beliefs

Identifying distorted thinking, or beliefsIdentifying distorted thinking, or beliefs

Changes behaviorsChanges behaviors


Cognitive Model of Emotional ResponseCognitive Model of Emotional Response

• Feelings Psychotic • Behaviors

• Situations• Events

Thoughts Thoughts Psychotic Symptoms

• Modifying the content of our thoughts that determine what type of emotions we feel

Benefit Benefit Cognitive Behavioral

CBT takes as its primary focus the dysfunctional experiencesCBT takes as its primary focus the dysfunctional experiencesBiological i

p y y pEvent Thought Feeling Actions Resultsp y y pEvent Thought Feeling Actions Results

Psychosocial Vulnerability Model

Cognitive Behavioral TherapyC i i M d l f E i l RC i i M d l f E i l RCognitive Model of Emotional ResponseCognitive Model of Emotional Response

PsychoticPsychotic Symptoms ThoughtThought

Cognitive Behavioral

BehaviorBehaviorEmotionEmotion

Biological i

When PDP patients develop psychotic symptoms, it is completely different from a patient who is diagnosed with primary psychosis. The


PDP patient is ego syntonic with the attributions of the developed symptoms. According to patients, they realize their hallucinatory and delusional state.


Stress Vulnerability Model Zubin and Spring (1977)Stress Vulnerability Model Zubin and Spring (1977)

PsychoticPsychotic Symptoms

Genetic predispositionGenetic predisposition


In the case of patients

di d i h

Biological i

diagnosed with PDP

Alternativeenvironmental factors

Alternativeenvironmental factors



Stress Vulnerability Model Zubin and Spring (1977)Stress Vulnerability Model Zubin and Spring (1977)

Psychotic Psychotic symptoms in a patient diagnosed with PD particularly visual hallucinationsPsychotic symptoms in a patient diagnosed with PD particularly visual hallucinationsPsychotic Symptoms

Psychotic symptoms in a patient diagnosed with PD, particularly visual hallucinations and paranoid delusions, occur in up to 60% of patients who receive dopamine (DA)

replacement therapy (Meltzer, et al., 2010).

Psychotic symptoms in a patient diagnosed with PD, particularly visual hallucinations and paranoid delusions, occur in up to 60% of patients who receive dopamine (DA)

replacement therapy (Meltzer, et al., 2010).


As a result, antipsychotic drug treatment is often used to manage persistent and troublesome psychotic symptoms in PD patients.

As a result, antipsychotic drug treatment is often used to manage persistent and troublesome psychotic symptoms in PD patients.

Biological i

There is no FDA pharmacological treatment approved for PDP in the United Stated or There is no FDA pharmacological treatment approved for PDP in the United Stated or Psychosocial Vulnerability Model

anywhere else in the world. The doses needed to block limbic D2 receptors, they also block dorsal striatal D2 receptors, reducing the ameliorative effects of L-dopa or direct

acting DA agonist treatment on motor symptoms.

anywhere else in the world. The doses needed to block limbic D2 receptors, they also block dorsal striatal D2 receptors, reducing the ameliorative effects of L-dopa or direct

acting DA agonist treatment on motor symptoms.

Methodology

Participants in this study were recruited

Dominican Republic Participants MethodologyDominican Republic Participants Methodology

Physical - Family Member

from the medical center Fundacion Activo20-30 Inc. in Santo Domingo Este in theDominican Republic. 50%

60%

70% 65% (13)

p

The study was conducted with a total offive patients (n=5) identified with PDP for

30%

40%

50%

25% (5)ntaj

e de

Enc

uest

ados

inclusion in the study. Four patients weremale and one female, and all over 65 yearsof age. All (five) patients where on 10%

20%

% ( )

5% (1) 5% (1)

Porc

en

of age. All (five) patients where onatypical psychiatric and dopaminergicpharmacological treatment.

0%Nothing A little Normal Pretty Extremly

0% (0)

Assessments and MeasureWorld Health Organization Quality of Life(WHOQOL)World Health Organization Quality of Life(WHOQOL)World Health Organization Quality of Life(WHOQOL)World Health Organization Quality of Life(WHOQOL)

I h i di id l' i i h f h i l dI h i di id l' i i h f h i l dPsychotic It assesses the individual's perceptions in the context of their culture and value systems, and their personal goals, standards and concerns.

It assesses the individual's perceptions in the context of their culture and value systems, and their personal goals, standards and concerns.

I i 26 i hi h h f ll i b d d i h i lI i 26 i hi h h f ll i b d d i h i l

Psychotic Symptoms

Instrument comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships, and environment.

Instrument comprises 26 items, which measure the following broad domains: physical health, psychological health, social relationships, and environment.

The scientific impact of this research may be measured heterogeneously. CBT for PDPThe scientific impact of this research may be measured heterogeneously. CBT for PDP


The scientific impact of this research may be measured heterogeneously. CBT for PDP is the first of its type conducted in the Dominican Republic and no reference is found in

another country.

The scientific impact of this research may be measured heterogeneously. CBT for PDP is the first of its type conducted in the Dominican Republic and no reference is found in

another country.

The World Health Organization (WHO) approved its Quality of Life assessment tool aThe World Health Organization (WHO) approved its Quality of Life assessment tool aBiological

i The World Health Organization (WHO) approved its Quality of Life assessment tool a novelty in the PDP population.

The World Health Organization (WHO) approved its Quality of Life assessment tool a novelty in the PDP population.


Assessments and MeasureAssessments and MeasureAssessments and Measure

Positive and Negative Syndrome Scale (PANSS) Spanish versionPositive and Negative Syndrome Scale (PANSS) Spanish version

Assessments and MeasureAssessments and Measure

Psychotic Positive and Negative Syndrome Scale (PANSS) Spanish version. Positive and Negative Syndrome Scale (PANSS) Spanish version.

Symptom Checklist-90-Revised (SCL-90-R) Spanish version

Symptom Checklist-90-Revised (SCL-90-R) Spanish version

Psychotic Symptoms

(SCL 90 R) Spanish version.(SCL 90 R) Spanish version.

World Health Organization Quality of Life Instruments (WHOQOL-BREF) Spanish

World Health Organization Quality of Life Instruments (WHOQOL-BREF) Spanish


Diagnostic Statistical Manual 5(DSM-5) Spanish Edition

Diagnostic Statistical Manual 5(DSM-5) Spanish Edition

Biological i

Mini Mental Status Exam (MMSE)Mini Mental Status Exam (MMSE)Psychosocial Vulnerability Model

Physical LimitationsTh R hTh R hThe ResearchThe Research

The research investigated the experience of people living with PDThe research investigated the experience of people living with PDPsychotic

Managing self Managing self

Medication in connectionMedication in connection

Psychotic Symptoms

Th t d di ti i h d th lit f lif f li i ith PD

Medication in connectionMedication in connection

MindMind BodyBodyCognitive Behavioral

The study distinguished the quality of life of living with PD.Mind-Brain identity in a theoretical perspective is more thana brain state is a mental states, the implication of this studywas the event, involved in explaining how the mind emergesBiological

i, p g g

from the brain. The mind is an epiphenomenon, withinfluences on the physical world.


Help Individual with Parkinson’s Disease and Care GiversCorrelationCorrelation • The increasingly worsening states of those with

PD make it necessary to provide patient care andsupport. Usually, the role of family members inDominican Republic, especially the patient’s

SignificantCorrelation SignificantCorrelation

partner.• In this investigation we found that there is a

relation between the seriousness of the motorsymptoms and non-motor symptoms specifically,

BetweenBetween

Patients worsening of

Patients worsening of Caregiver’s

burdenCaregiver’s

burden DepressionDepression

• The presence of PD and its chronicitysignificantly increases caregiver burden anddecreases the quality of life However even mild

RelationRelation

symptoms and non motor symptoms specifically,depression in patients diagnosed with PD and acorrelation of the burden on caregivers.

symptomssymptoms burdenburden

decreases the quality of life. However, even mildlevels of depression/psychosis increasesdisability and overall functional impairmentprogress in tandem with personal care decline. Motor

t Non Motor• PD has been found to affect the individuals’ life,as well as their family members.

symptoms Non-Motor symptoms

File PANSS Scale System

6

Positive Scale

4

5

SPO

ND

ENTS

2

3

NU

MB

ER O

F R

ES

0

1

Absent Minimal mild Moderate Moderate Severe Severe Extreme

N

Delusions Conceptual Disorganisation Hallucinatory Behaviour ExcitementGrandiosity Suspiciousness/persecution Hostility

File PANSS Scale System

Positive Scale

5

3.5

4

4.5

nden

ts

ExcitationHostility

1.5

2

2.5

3

Num

ber

of R

espo

n

Delusions

0

0.5

1

ABSENT MINIMAL MILD MODERATE

N

ABSENT MINIMAL MILD MODERATE

Delusions Disorganization Conceptal Hallucinations Behavior Excitation Grandiosity Mistrust / Persecution Hostility

PSYCHOLOGICAL - PTPsychological SymptomsPsychological Symptoms Tenth Week Improvement Psychological SymptomTenth Week Improvement Psychological Symptom

Psychological Symptoms Tenth Week Improvement Psychological Symptoms

50%

60%

45% (9)

55% (11)

100%

120%

20

25

Psychological Symptoms

30%

40%

aje

de E

ncue

stad

os

60%

80%

10

15

10%

20%

Porc

enta

0%

20%

40%

0

5

0%A little Modorate

0%0Moderate Normal Total

Series1 Series2

Psychological -FMPsychological SymptomsPsychological Symptoms Psychological SymptomsPsychological Symptoms

Psychological Symptoms Psychological Symptoms

35%

40%

45%44% (7)

31% ( )35%

40%

45% 42% (10)

25%

30%

35%

25% (4)

31% (5)

e de

Enc

uest

ados

20%

25%

30%29% (7)

25% (6)

e de

Enc

uest

ados

10%

15%

20%

Porc

enta

je

10%

15%

20%

4% (1)

Porc

enta

je

0%

5%

Nothing A little Moderat0%

5%

Nothing A little Moderat Pretty

4% (1)

PHYSICAL HEALTH - PT

70%

80%

90% 84%

40%

50%

60%52%

ntag

e of

Res

pond

ents

Series1 Series2

10%

20%

30%

15%11%

22%

0%4%

12%

Perc

en

0%Nothing A little Moderate Much Extreme

0%

PHYSICAL HEALTH - FMPhysical - Family MemberPhysical - Family Member Physical - Family MemberPhysical - Family Member

Physical - Family Member Physical - Family Member

50%

60%

70% 65% (13)

50%

60% 57% (12)

30%

40%

50%

25% (5)ntaj

e de

Enc

uest

ados

30%

40%

29% (6)

ntaj

e de

Enc

uest

ados

10%

20%

25% (5)

5% (1) 5% (1)

Porc

en

10%

20%14% (3)Po

rcen

0%Nothing A little Normal Pretty Extremly

0% (0)0%

Nothing A little Normal Pretty Extremly

0% (0) 0% (0)

Social Relationship - FMQuality of Life Measure Quality of Life Measure

Social RelationshipSocial Relationship

60%

70%63% (19)

30%

35%

40%

33% (10)

37% (11)

40%

50%

37% (11)

de E

ncue

stad

os

20%

25% 23% (7)

aje

de E

ncue

stad

os

10%

20%

30%

Porc

enta

je d

5%

10%

15%

7% (2)

Porc

enta

0%The normal Normal

0%very

Insastifecho/aInsastifecho/a Normal pretty

Satifecho/a

Quality of Life Measure

Social RelationshipSocial Relationship Social RelationshipsSocial Relationships

Social Relationship

50%49% (20)

Social Relationship

40%

45%

50% 46% (16) 46% (16)

s

35%

40%

45%

50%( )

41% (17)

46% (16) 46% (16)

esta

dos

20%

25%

30%

35%

age

of R

espo

nden

ts

15%

20%

25%

30%

9% (3)Porc

enta

je d

e En

cue

Series1Series2

5%

10%

15%

20%

9% (3)Perc

enta

0%

5%

10%5% (2)

2% (1) 2% (1)

9% (3)

0% (0) 0% (0)P

0%very Insastifech/a Insastifech/a Normal

Dominican Cultural Practice

• The four wives of the patients that

La Familia & La CasaLa Familia & La Casa

Family IdentityFamily Identity e ou w ves o e pa e s a

participated in the investigation assistedtheir spouses diligently and with

ibilit i th i l i

de yde ySources of value and support to Dominican

Sources of value and support to Dominican responsibility in their role as caregiver.

• The only female patient in this study didnot have family support and no significant

Family SupportFamily Support

o caFamilieso caFamilies

not have family support, and no significantimprovement was noted. The family “lafamilia” has a sense of responsibility thatl d l i h h h l

We recognized that Dominican’s valuetheir families and identify their familiaas a source of identity and support in

leads to volunteerism that the house “lacasa” is the center of care.

y pptimes of crisis.

Conclusion

In this study, the researchers took several measures to ensure the most

Conclusion & RecommendationsConclusion & Recommendations

y,accurate results were obtained and the objectives of the study wereachieved. In the country there was no available statistics that can beused to quantify the PD population, the prevalence PD is hard to know.q y p p , pThis study found that hallucinatory phenomena in PD are more frequentthan have been described in previous studies.

Questions ?

cognitive behavioral therapy an evidence based treatmentan ...€¦ · diagnosis and epidemiology...

Documents