SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY

SEVEN PEARLS FOR EFFECTIVE COGNITIVE BEHAVIORAL THERAPY


Research has proven that by identifying our distorted thoughts and beliefs, we can have better control over thoughts, thus better control over our feelings. Having distorted thoughts or beliefs doesn't mean that there is something wrong with us. We all have distorted thoughts and beliefs at different times in our lives. 

Some examples of distorted thoughts:



OVER-GENERALIZING: At times, we may see things as all-or-nothing. For example, if one thing goes wrong with a project, we may think that the entire project is a failure. Or, if there is one thing that upsets us about a person, we may decide we don't care for that person at all.



MIND READING: We assume that we know what someone is thinking. We may tell ourselves that someone thinks we are "stupid" or does not like us even though there is no evidence that supports this thought. This is called mind reading.



CATASTROPHIZING: We exaggerate how "awful" something is or imagine the worst possible outcome. Perhaps our boss wants to speak with us and we catastrophize that we are going to be fired. Or, it rains on one of the days of a vacation and we think "this is the worst thing that could have happened".



FORTUNE TELLING: We think we know for sure what is going to happen. For example, we tell ourselves, "I know I am not going to get that promotion" or "I won't be able to handle that assignment". 

In addition, specific behaviors or skills are taught including social skills, assertiveness, organizational skills, and relaxation techniques. These are taught during and between sessions. 

   

Below, are seven pearls that I will share with you that I have found helpful over the years in my practice:

  

1. DISCUSS GOALS OF TREATMENT

During the initial assessment phase, it is important to collaborate on the goals of treatment. This helps keep the treatment focused and productive. Without goals, therapy can end up focusing on whatever problem is coming up that week and can interfere with progress of the original presenting problems. Sometimes, the patient may not be able to specifically describe a goal except a vague "I want to be less anxious" or "I want to feel happier".  This is fine at the beginning. However, over the first couple of months, you should return to this discussion about goals to see if they can be described in more specific terms. 

For example, if someone presents with depression, the goals may include the following: Finding a more fulfilling job, returning to college, exercising three times a week, making two new friends, and stopping the use of marijuana.

2. START EACH SESSION WITH AN AGENDA

Every session should start with an agenda that is discussed collaboratively between the therapist and the patient. Again, this helps to keep the session focused and more effective. The agenda should include following up on homework from the previous session, a check-in about the mood and week, bridging or reviewing the topics and progress from the previous session, and topics related to discuss in the current session that is related to a specific goal.

3. DISCUSS WHERE TO ADDRESS THE ISSUE

Most therapy goals will have several components including distorted thoughts, beliefs or behaviors. Thus, during the session, collaboratively decide on which level to address the goals. If you are working on distorted thoughts, it is important to elicit what thoughts or images occur that are leading to the distress, such as anxiety, low mood, or blocking a certain behavior. If you are working on certain behaviors such as social skills or relationship issues, it is important to discuss when the skills will be used and how likely it is the skills will be used. Another useful technique for addressing behaviors is role playing and visualizing which helps to practice the skills and address any blocks or anxieties around the behavior.

4. USE FLASHCARDS

Flashcards can be used to remember the key points of the session or a mantra that may help with certain thoughts or feelings. If I am working with a patient who is struggling with depression, I will title the flashcard something like "Survival Kit" and it will include strategies to cope with the depression such as reaching out to a friend, getting out of the house, reaching out to me, or taking care of a small chore.

5. STAY FOCUSED

At the beginning of treatment, goals for therapy are discussed. Sometimes, the therapy session may head in a direction that is unrelated to any of the goals of treatment. This is appropriate at certain times, but if this is happening every session and for the entire duration, then there can be a limit to the progress of therapy. Structure is important in CBT, but flexibility is also important. This would be a time to collaborate to discuss whether to continue on the current diversion or issue that is being discussed or go back to what was discussed in the agenda.

6. ASSIGN HOMEWORK

Towards the end of each session, a collaborative discussion takes place about homework or "action tasks" to perform between sessions. An action task might be to buy a calendar if one of the issues is time management or recording thoughts and images that occur during stressful periods in a notebook to discuss and address at the following session. Always make sure to follow-up on the homework or action task at the next session or it creates the impression that working on problems or goals in between sessions is not a crucial part of getting better.

7. ASK FOR FEEDBACK

Towards the end of the session, ask what went well during the session, what could have gone better, and what the main take-away messages are. This helps to build the alliance, improve future sessions, and maximize progress.

Cognitive behavioral therapy is an extremely effective form of therapy, either with or without medications and is an excellent way to practice psychiatry.

 

If I can be of help or you have any questions about cognitive behavioral therapy, adult ADHD or medications, please feel free to email me at scott@scottshapiromd.com or call 212-631-8010.

Scott

Scott Shapiro, MD, FAPA

First FDA Approved Scan for ADHD--7 Things to Know about ADHD and Brain Scans

The FDA recently approved the first mental health diagnosis to use a brain scan called an electroencephalogram, or EEG, that measures electrical impulses in the brain.  The EEG records different brain wave patterns including alpha, beta, delta, and theta waves.

In children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD), the ratio of theta to beta waves has been shown to be higher. The FDA approved test is called the NEBA, the Neuropsychiatric EEG-Based Assessment Aid System.

The study used to receive FDA approval included 275 children and adolescents. The study concluded that NEBA can assist in the diagnosis of ADHD amongst children and adolescents.

Here are 7 Things to Know about NEBA:

1.    The test takes 20 minutes to complete.

2.    As with all tests results such as labs and x-rays, the information should be used with other clinical assessments such as a psychiatric evaluations and questionnaires.

3.    This test has only been approved in people aged 6-17 years old.

4.    It has NOT been approved for adults but may eventually prove beneficial.

5.    In the future, more sophisticated scans such as the functional MRI (fMRI) may aid in the diagnosis of ADHD. 

6.    Eventually, the NEBA may assist in other mental health assessments such as depression, bipolar disorder, and autism.

7.    In my opinion, further research is necessary prior to recommending the NEBA due to the limited size of the study.

The NEBA is the first FDA-approved scan to assist in a psychiatric diagnosis and eventually may be used for other disorders. In addition, it could lead to further research in using more sophisticated scans in the diagnostic process. At this time, I feel further research is necessary before using this tool clinically.

Resources:

Goldberg, Dan. Brain wave scan, approved by FDA, could help detect ADHD. Star-Ledger On-Line. July 17, 2013.

Park, Alice. Reading the Brain: FDA Approves First Scan for Diagnosing ADHD. Time Magazine On-Line. July 16^th, 2013.

5 Easy Steps for Diagnosing Adult ADHD

5 Easy Steps for Diagnosing Adult ADHD

The proper diagnosis of Adult ADHD can be confusing and overwhelming; many of the symptoms overlap with other disorders and many of the symptoms are set along a wide spectrum. Additionally, most clinicians have not been extensively trained in the accurate diagnosis of Adult ADHD.

This is a brief and simple step-by-step guide to the diagnosis of Adult ADHD so that you can feel more confident in assigning the diagnosis and referring to a therapist and/or psychiatrist who specializes in the comprehensive treatment of Adult ADHD.

 Step 1: Ask these key screening questions:

1.  Do you have difficulty reading magazines, books, or maps?
2.   Do you have a messy office or home?
3.   Do you have trouble starting and/or completing projects?
4.   Do you often feel mentally “foggy” or “in a haze”?
5.   Do others say you tend to jump from topic to topic in conversation?
6.   Have you received negative feedback, such as inconsistent performance, in your school or work reviews?
7.   Have you had any or all of these problems since childhood?
8.   Which family members, if any, have depression, anxiety, mood swings, or problems with attention and focus?

Step 2: Administer the ADHD Screening Exams called the ASRS v1.1 and the Epsworth inventory on all patients.

Step 3: Gather collaborative information:

Many young adults may try to receive a diagnosis of ADHD in order to get stimulant medications even when they do not have ADHD, so it is critical to review collaborative information whenever practical. 
Assess past report cards and performance reviews for clues pointing toward ADHD.
Always speak to family members, whenever possible.

 Step 4: Administer the Conners Test

This is the gold standard for inventories and is, in fact, superior to neuropsychiatric testing. The diagnosis of ADHD is a clinical diagnosis and does not require neuropsychiatric testing unless you are also evaluating for learning disabilities. 

Step 5: Rule out medical or psychiatric disorders that can mimic or coexist with Adult ADHD:

There are many medical and psychiatric disorders that can mimic the symptoms of Adult ADHD. These are a few conditions that may exhibit similar symptoms:
1.   Chemotherapy
2.   Menopause
3.   Sleep apnea
4.   Insomnia
5.   Bipolar Disorder, depression or substance abuse
6.   Medications such as blood pressure medications and antibiotics
7.   Multiple Sclerosis, seizures, HIV, head injuries

How do you distinguish these scenarios from Adult ADHD?  After taking a detailed history, determine whether the symptoms began after early adolescence. If so, it is NOT ADHD. If the symptoms fluctuate, it is NOT ADHD.

It should be noted that in certain situations, such as menopause, depression, or chemotherapy, stimulants are commonly used and are effective for the treatment of poor focus and attention, distractibility, and low motivation. 


Following these simple steps, you as a clinician can more effectively diagnosis and refer your patients who most likely have Adult ADHD or present with similar symptoms. It is important that this provider has had specialized training in the diagnosis and treatment of Adult ADHD.

Time Management Tips for Adult ADD/ADHD

Adult ADD/ADHD causes more significant impairment than difficulty with mental focus. ADD impairs executive functions including planning, strategizing, impulse control, emotional regulation, and organizational skills.

Time management includes the utilization of all of these skills and thus is often impaired in people with Adult ADD. Patients often miss deadlines, procrastinate, and are often chronically late to appointments and events. This obviously can take a toll on a career, relationships, and family.

Thus, in this newsletter, I am going to provide five tips you can use to help people with Adult ADD who are chronically late.

Tip # 1 – MULTIPLY TIME ESTIMATES BY THREE

ADD often causes people to underestimate the time required for an activity or travel from point to point. When I mention this issue to people with Adult ADD, they often smile because it has been an issue their entire lives. Thus, I recommend multiplying their time estimates by three to build in a buffer against lateness.

Tip # 2 – AVOID "JUST IN TIME" THINKING

Most people hate to wait, but people with Adult ADD find it even more intolerable. Thus, they often plan on arriving just in time to avoid waiting. I help people with Adult ADD recognize this tendency and to adopt a firm policy of arriving early. In order to reinforce this behavior, I encourage them to use the extra time to do something they enjoy such as reading a book, playing a video game, or catching up on emails.

Tip # 3 – MAKE IT A HABIT

For many people with Adult ADD, being late has become a life-long habit. Research has shown that effectively changing a habit takes 21 days of consistent behavior. Often, people I am helping will say that they will be on time for important appointments or projects but not for “important” activities. However, unless people adopt their new habit to all of their activities and projects, the chances of success are much lower. Thus, I encourage people with Adult ADD to treat all projects and appointments equally to change the habit of lateness.

Tip # 4 – BUILD THE DISCIPLINE MUSCLE

Time management requires a significant amount of discipline. Often, people with Adult ADD have been frustrated in so many areas of their lives that they have given up on many challenges or exerting the extra discipline that many tasks require. Discipline is like a muscle and the more you use it, the stronger it develops. I encourage people with Adult ADD to practice discipline in multiple areas of their lives whether it is exercising five more minutes than usual, deciding not to drink that extra cup of coffee, or avoiding the internet and email for three consecutive hours. I have seen people with ADD realize a tremendous amount of success improving their discipline in several areas, including time management.

Tip # 5 – HAVE A SCHEDULE

People with Adult ADD often pack their schedules without allotting time for travel or having a buffer zone. They often don’t have a schedule at all and just improvise. Thus, I encourage people with Adult ADD to use a schedule each and every day of the week. The schedule should consistently include all meetings, projects and tasks as well as blocking out times when projects should be started or extra time to allow for travel. This often helps people with Adult ADD manage their time by improving planning and strategizing.

Please feel free to share these tips with your clients or patients with Adult ADD. Teaching people with Adult ADD time management strategies can make a significant impact on their overall functioning and quality of life.

For more information, contact Dr. Shapiro at 212-631-8010 or scott@scottshapiromd.com.

Scott Shapiro, MD

Assistant Professor of Psychiatry

New York Medical College

Specializing in Adult ADD/ADHD

www.scottshapiromd.com

Bibliography:

Barkley, R., Kevin Murphy. Attention-Deficit Hyperactivity Disorder. A Clinical Workbook. Guilford Press. 2006.

DeLonzor, Donna. Never Be Late Again. A Clinical Workbook. Post Madison Publishing. 2003.

Young, S., Jessica Braham. ADHD in Adults. John Wiley and Sons Ltd. West Sussex, England. 2007

Schema Therapy-Evidence Based Psychotherapy

Have you ever noticed certain patterns in your life such as dating the wrong type of person or getting angry in similar situations? 

Have you wondered why you haven't achieved the success you want in your career or personal life? Do you often feel like an outsider or feel defective?

Schema therapy is a form of cognitive therapy that helps us to understand why we act and feel the way we do.  And, it goes beyond this. It helps you to make changes in your life to feel more satisfied in your relationships, work, and personal life. 

Schemas are life long patterns of feelings and memories that are influenced by our experiences growing up. We all have schemas. Some schemas help us move in the direction of our goals and some schemas thwart our efforts. 

Schema therapy is an interactive and goal oriented therapy that has several components; assessment, experiential, and behavioral. During the assessment, schemas are identified that are interfering in one's life. Then, during the experiential phase, tools such as imagery, flash cards and dialogues are used to deeply understand and recognize how the schemas are interfering in achieving one's goals and how these can be changed. Finally, during the behavioral phase, the therapist and patient works collaboratively on achieving significant changes that are long lasting.

Examples of Schemas:

Defectiveness: You often feel that there is something wrong with you as a person. You don't feel that you are "ok" no matter how successful you are in your life. This schema often occurs if you experienced bullying, chronic criticism, or severe abuse. 

Social Isolation: You often feel like you don't belong or feel uncomfortable with certain groups of people.  This may lead you to avoid social gatherings, certain work environments, or dating. You may also feel so anxious at events that you turn to alcohol or drugs to cope. This schema may occur if you felt different or excluded growing up. This can occur due to differences in ethnicity, religion, finances, or sexual identity.

Self-Sacrifice: You feel that other people's needs are more important than your own. You often ignore your own desires and preferences because you either feel that you don't deserve much or you feel guilty. This schema can develop if we grew up in a family where there was alcohol abuse, a medical illness, or an impaired parent.

Unrelenting Standards: You feel that you must always excel and push yourself to succeed; you may have difficulty relaxing or being spontaneous. People with this schema often struggle with feeling tired, anxious and irritable. This schema develops when excessively high standards are imposed on you during childhood.

Schema therapy addresses and changes long-standing problems such as depression, anxiety, substance abuse, sexual addiction, and personality disorders. To learn more about schema therapy, there is an excellent book written by the founder of schema therapy, Jeffrey Young, PhD, titledReinventing Your Life.

5 Tips to More Satisfying Treatment with Your ADHD Patients

5 Tips to More Satisfying Treatment with Your ADHD Patients

Sometimes, it seems like everybody either has ADHD or thinks they have ADHD. However, only 5% of adult patients have true ADHD. In addition, the symptoms can present differently in adults than they do in children. 

In adults, the most debilitating problems resulting from ADHD are the executive functions such as:  planning, prioritizing, impulse control, maintaining motivation, organizing, and working memory. Patients with ADHD can be frustrating for the patient and their families as well as the doctors who are treating them.

I will describe some of the ways that ADHD can impair our patients' health and safety and then discuss some ways that you can help your patients.

How does impaired executive functioning affect the health of our patients?

1.     Higher risk of substance abuse - 10-25% prevalence

2.     Late or missed medical appointments

3.     Non-compliance or missed medications

4.     Increase impulsivity and risk of contracting STDs

5.     High prevalence of motor vehicle accidents

6.     Underperforming at work

7.     Low self-esteem

8.     Increased risk of depression and anxiety

9.     Difficulty with sleep

10.  Trouble with relationships

5 ways that we can help our patients:

1.     Many patients are often not diagnosed as children. Thus, by using a simple 5 minute screening tool in the office or waiting room, we can help our patients that may have been misdiagnosed as borderline, chronically depressed, anxious or bipolar disorder. 

Here is a site that you can give your patients:

http://counsellingresource.com/lib/quizzes/adhd-testing/adhd-asrs/

Many patients feel that ADHD is not a "real diagnosis" and thus don't get evaluated or treated. However, by explaining to the patients that SPECT and PET scans show differential blood flow in the prefrontal cortex in ADHD patients versus non-ADHD patients can help reinforce to the patient that this is a "real" issue.

2.     Patients with ADHD have difficulty with planning and time management. Thus, they often forget their appointments or are late. 

This can be extremely annoying for a busy clinician, in addition, to the patient not getting the necessary care. 

Thus, a way of improving the show rate for these patients includes encouraging them to write the appointment in their calendars immediately when the appointment is made, requesting that they show up 30 minutes before their appointments, calling them the morning of their appointments (not the night before) and by charging them for missed appointments.

3.     Encouraging your patients to purchase a weekly calendar and to use it on a regular basis instead of relying on post-it notes or on smart phone. Many ADHD patients do better when they see things visually.

4.     Help the ADHD patient to see that they have many strengths and that ADHD is just one aspect of who they are. In addition, even though they have compensated for it most of their lives, validate that it may have been a difficult struggle and that it can get better.

5.     Help the patient to understand that many of their behaviors such as underperforming at work, engaging in high risk sexual activity, or challenges in their relationships are very common in patients with ADHD and that this can get better over time with treatment, either medications or behavioral treatments.

Working with patients who have ADHD can be frustrating at times, but can be extremely rewarding. Just like cigarette cessation, it can have a significant impact on a patient's life, but with appropriate diagnosis, treatment, and intervention, a patient's health and well-being can greatly improve.

Scott Shapiro, MD

www.scottshapiromd.com

212-631-8010

Bibliography:

Barkley, R., Kevin Murphy. Attention-Deficit Hyperactivity Disorder. A Clinical Workbook. Guilford Press. 2006.

Young, S., Jessica Braham. ADHD in Adults. John Wiley and Sons Ltd. West Sussex, England. 2007

Adult ADHD and Insomnia

Adult ADD/ADHD and Insomnia -

Insomnia is very common in Adult ADD/ADHD and often overlooked by professionals. Also, insomnia is often under-reported and under-treated since patients are often focusing on other medical issues when they visit their doctor or they haven't found relief from their insomnia from previous treatment.

Insomnia and chronic sleep deprivation can have a significant impact on many areas of a person's life including.

- Decreased job performance

- Impaired focus and concentration

- More frequent car accidents

- Increased risk of suicide

- Worsening health condition

- Poor medication compliance

By addressing and treating a person's insomnia, you can make a great impact on the quality of life. There are many causes of insomnia and many of them are overlapping. Some of the most frequent causes include:

- Working late

- Computer, Internet, IPAD before bed

- Exercising in the late evening

- Depression and anxiety

- Reflux

- Restless leg syndrome

- Sleep Apnea

- Substance abuse

- Medications ex. antidepressants, stimulants, steroids

In addition, insomnia is very common in psychiatric problems such as depression and anxiety. “A useful rule of thumb is that insomnia more commonly precedes a depressive episode, and more commonly follows an episode of anxiety”¹.

When a patient presents with a sleeping problem, it is crucial to understand the potential cause(s) of the sleeping problem.

Here are ten essential questions to ask:

When did your sleeping problem start?

Are there any changes at work or home?

Have you started any new medications or supplements?

When do you work out?

Do you snore or kick your partner?

Have you had this problem before?

What treatments have helped in the past?

What medical problems do you have?

Do you have a history of depression, anxiety or ADHD?

How many times a week do you drink? What do you like to drink?

There are numerous treatments available for insomnia. A key principle to keep in mind is that “…[N]onpharmacologic therapy for insomnia should be attempted first, and benzodiazepines should probably be reserved for patients not responding to nonpharmacologic combined with nonbenzodiazepine pharmacologic therapy.”²

Here are some tips on medications that I have found helpful for my patients:

1. Ambien is an intermediate acting medication. It should be taken on an empty stomach. It is recommended to use for only 2 weeks, but often I have found that patients require longer periods of use.

2. Sonata has a very short half-life. Thus, it is useful for the patients that are able to fall asleep but wake up at 4 or 5 am and need an additional 2-3 hours of sleep without a hangover. This also should be taken on an empty stomach.

3. I rarely use Lunesta because it has a high rate of the side effect of a metallic taste. This occurs in 40% of patients.

4. Another medication that I often like for patients is Trazodone. This is an off-label use. I prescribe 25- 100 mg at night. There is a risk of hypotension and thus a risk of falls. I rarely use it in men because of the risk of a priapism. If it is used with men, this risk must be discussed with the patient prior to prescribing.

5. Seroquel is another medication that I prescribe off-label. Even though there is a risk of metabolic syndrome and other side effects, I have found this medication to be very help, especially in patients with PTSD, bipolar disorder or chronic insomnia.

6. I try to avoid benzodiazepines such as Klonopin (clonazepam) and Xanax (alprazolam) because they often help with anxiety and insomnia initially; however, the sedative effect often wears off over time.

7. Tricyclic antidepressants such as Tofranil may also be helpful in small doses. Some of the common side effects include dry mouth and constipation.

8. Clonidine 0.1-0.2 mg can be an effective off-label treatment for insomnia, especially in patients with Adult ADD/ADHD and PTSD.

Insomnia is very common and a careful history and assessment along with effective treatments can greatly help your patient have a better quality of life.

Scott Shapiro, MD is a Harvard-educated psychiatrist in New York City. He specializes in Adult ADHD and Cognitive Behavioral Therapy (CBT). Learn more about Dr. Shapiro at www.scottshapiromd.com or call 212-631-8010.

References:

1. Flaherty, Kelleen. The Carlat Report, November 2011, Vol 9, Issue 11.

2. Smith, Howard, et. al. American Journal of Therapeutics. 18 (3): 227-40, May 2011.

Disclaimer

The material contained here is not intended in any way to replace proper medical supervision or advice. All decisions which may impact your health should be discussed with your physician.

If you are under the care of a physician or are taking medication, consult your physicians before changing or discontinuing any medication or current medical treatment. Implementing new items may alter your medication needs. Adjustments of prescribed medications should only be done under the direct supervision of your physician.

Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. If you have or suspect that you have a medical problem, promptly contact your health care provider.
All photos included in the header of this site are models and are in no way associated or under the care of Dr. Shapiro.