ECSP st European Congress for Social Psychiatry 4th-6th July 2012

Transcription

1 ECSP st European Congress for Social Psychiatry 4th-6th July 2012 Dr. Marco Passoni Dr. Valter Micieli Dr. Sara Fumagalli Orselina- CH

2 INTRODUCTION: OUR EXPERIENCE Admission per year Days of inpatients care Days in common room Epidemiology in PDs

3 HETEROGENEITY AND SEVERITY OF PDS Prevalence= 3,9-15,7% (Kessler et al.,2009) comorbidity and social disfunctioning cost > depression and anxiety disorders (Soeteman et al.,2007; Clark et al., 2005). Diagnostic and therapeutic problem (Shedler J., Beck A., Fonagy P., Gabbard G.O., Gunderson J.G., Kernberg O.F., Michels R. & Westen D. (2010) Treatment target: core symptoms(fonaghy & Bateman )

4 AIM OF RESEARCH FOR PATIENTS Reduce impulsive behaviors, suicidal and parasuicidal behaviors Improve compliance and insight for future treatment Improve individual performance Find new strategies that reduces the risk of acute relapse, access to emergency unit. Encourages long term treatment. FOR CLINICIANS Train an integrated team to be expert in this technique. Reduce acting out in treatment team Reduce burn out in therapists Improve and facilitate the mental health networking

5 MENTALIZATION BASED TREATMENT Accordingly to Fonagy & Bateman we claim no originality in MBT that summarize different theories and approach i.e.: MENTALIZATION BACKROUND no breast, therefore imagine (mentalize) a breast (Freud) depressive position as acquisition of mentalizing (Klein) a capacity for tolerating frustration thus enables the psyche to develop thought as a means by which the frustration that is tolerated is itself made more tolerable. (Bion) maternal mirroring support a mentalized sense of self (Winnicot) MBT GOALS Helps patients regulate their thoughts and feelings. Avoid iatrogenic effects of other treatment (sense of not-knowing ). BIOLOGICAL ASPECTS OF MB Mirror neurons (premotor cortex) are involved in the processes of mentalization (Ramnani et al., 2004) The prefrontal cortex/amygdala are essential for mentalizing(gallagher et al., 2000, Schore et al., 2003) Impulsivity, acting out trend, aggression are associated with a metabolism deficit of serotonin. (Beitchman et al., 2003)

6 STUDY S DESIGN Inclusion criteria 1.diagnosis of PDs 2.age ENROLMENT Exclusion criteria: 1. not able to follow up 2. Psychotic or bipolar (I) disorder or 3. drug dependence 4. organic brain disorder. Mentalization based treatment (MBT) RANDOMIZATION &BASELINE ASSESMENT 18 month follow up Standard treatment team (STT)

7 MBT TREATMENT PLAN (TP) MBT team Patient Preliminary team brief before the admission of patients ADMISSION 1.weekly meeting for TP updating 2.biweekly case supervision 3.monthly case discussions STATIONARY TREATMENT (ABOUT 30 DAYS) DAY HOSPITAL TREATMENT (ABOUT 17 MONTH) AMBULATORIAL TREATMENT

8 SAMPLE DESCRIPTION AT T 0 Life events MBT (10) deth=1 STT(10) drop out=2 Females 7 (70%) 9(90%) Males 3 (30%) 1(10%) Age (years) 35, ,8 35,88+-7,83 Familiarity Comorbidity Education (years) 8,6 +- 0,66 10,88+-1,69 Not married 9 (90%) 10 (100%) Tentamen/year 1,8+-2,14 1,77+-1,64 Access PS/year 3,4+-2,01 1,88+-1,05 Inpatients treatment (days/year) 60,6+-51,68 78, ,29 AI 5 (50%) 7(70%) Previous treatment 10 (100%) 10(100%) Abuse-use substance last year Life events (sexual abuse, parents deth, etc) 7 (70%) 8(80%) 9 (90%) 10(100%) Familiarity 10 (100%) 6(60%) Comorbidity 9 (90%) 9(90%)

9 Description THERAPEUTIC PLAN PHASE I. Hospitalization (27 days), psychiatric assessment, individual psychot:3/week,, individual physiot: 2/week. Meanings To promote a dual relationship To vehicular care with body s communication To reinforce the therapeutic alliance PHASE II: DH 3/week, (6 months), psychiatric interviews, individual psychot. 2/week, group physiot.1/week. To introduce a third role in dual relationship To encourage, with body s communication channel the relationship with others. PHASE III: DH, 3/week (4 months) monthly psychiatric interviews, weekly individual&group psychot.; Art Therapy: 1/ week, occupational therapy:1/ week. To foster dialogue and relationship with group activities, To identifying new communication channels To promote creative expression To became able support the frustration PHASE IV: DH 2/week, protected outdoor activities 3/week protected work: individual psychot. once a week, art therapy, occupational therapy, interviews with family(every 2 months). to encourage the upgrading and reemployment to promote patient s autonomy

10 SWAP-200 PROFILE AT ONE YEAR P profile T0 T2 Q profile IN RED MOST SIGNIFICANT CHANGES

11 THINKING OVER CLINICAL CASE Reducing of suicidal risk factors. Therapeutic alliance and psycho pharmacological compliance are really improved. An overview is that patients has moved into psychotic autistic continuum (Ogden) from the disorganization paranoid phase to a matures one that is narcissism with significant increase in obsessive defences. Moving in depressive position support insight and mentalization in itself.

12 CONCLUSIONS Clinic s role: acute relapse as occasion of structural transformation instead of only protection. Improving in insight supports long term patient s compliance for future psychodinamic psychoterapy (TFT Kernberg, PI, P. Rocca, i.e.) Our methodological choice support integration of team care and relationship with community and could be useful in several diagnosis.