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1 Cognitive Behavioral Therapy an Evidence Based Treatment for Parkinson s Disease Psychosis Henry A. Montero, PhD Candidate, M.Sc., LMHC Fellow for Global Foundation for Development and Democracy
2 Table Of Contents / Index I t d ti Introduction Diagnosis and Epidemiology of Parkinson s Disease Parkinson s Disease Cognitive g Behavioral Therapy py Psychotic Symptoms Biological Psychosocial Vulnerability Model Cognitive Behavioral Therapy for Parkinson s Disease Psychosis Scientific Impact Literature Review Therapeutic Model Assessments and Measures F Focus off T Treatment Methodology Research Research Background Help Individual with Parkinson s Disease and Care Givers Dominican Cultural Practice Conclusion
3 Ph.D. Candidate Introduction Henry Montero Tapia Harold Abel School of Psychology - Capella University Master of Science Manhattan College - Licensed in the State of New York, New Jersey Bachelor of Arts Monroe College - Business Administration i ti and dcomputer Information Technology
4 Diagnosis and Epidemiology of Parkinson s Disease Parkinson s Disease is a neurodegenerative movement disorder, affecting over six million people worldwide (Parkinson's Disease Foundation, Inc., 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 condition. (extrapolation by Castillo, 2014 )
5 Diagnosis and Epidemiology of Parkinson s Disease The pathological finding associated with PD is the degeneration of dopaminergic neurons of the Pars Compacta of the Substantia Nigra leading to the depletion of dopamine in the striatum (Factor & Weiner, 2007) Symptoms for PD do not appear until 100% 80% 60% 40% 20% 0% 50-60% of the nigral neurons are depleted eted Depleted Neurons Nigral Neurons 100% 80% 60% 40% 20% 80-85% of the dopamine substance of the stratum is lost Dopamine Lost Wirdefeldt, Adami, Cole, Trichopoulos, & Mandel (2011) 0% Nigral Neurons
6 Parkinson s Disease Diagnoses 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. PD is determined based on criteria of Parkinsonian symptoms after a hypotheticdeductive process is confirmed. The idiopathic condition of PD is the presence of two or more of the conjoint symptoms: Resting tremors Rigidity Hyperki nesia Impaired postural reflexes According to Braak, Ghebremedhin, Rub, Bratzke, & Del Tredici (2004)
7 Diagnosis and Epidemiology of Parkinson s Disease Definition 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). 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 early detection and thus early intervention, which often results in a better quality of life.
8 Parkinson s Disease Psychosis Psychosis Joseph Freidman (2011) stated PDP should be diagnosed only after medical and environmental causes of delirium/dementia have been eliminated or addressed. Treatment with pharmacologic and psychotropic medication should be noted since implications exacerbate PD (Fujimoto, 2009).
9 Parkinson s Disease Psychosis Parkinson s Disease Psychosis (PDP) Consequently, elevated dopamine levels can trigger psychosis. For this reason, treatment often becomes a balancing act. Prominence of visual hallucinations Reduced quality of life The exact pathophysiology p of PDP remains unknown Parkinson's disease patients do not generally tolerate classical antipsychotic drugs.
10 Cognitive Behavioral Therapy (CBT) CBT is a method of treatment that focuses on examining i 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 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.
11 Psychological/Physical Perspective The individual is dealing with the gradual loss of abilities that accompanied by the progression of PD. In this capacity, the theoretical implication is based on Evidence Based Medicine (EBM) this practice delineates the degree in which a neuro-degenerative disease can impact the emotional wellbeing of a PD patient. According to Cochrane et al. (1989) from the EBM does not specify an approach that can epidemiological point of view EBM, can be account for the understanding of the impact and defined as consequences of patient s emotions/feelings, neither are there any opinions that can provide the psychology community with criteria to work from. The researcher will add a variable to EBM condition Treatment Outcome Condition Emotion Treatment Outcome A (Condition) + B (Treatment) = X (Outcome) A (Condition) / Y (Emotion) + B (Treatment) = X (Outcome) The PD patient has a condition that produce an emotion that will beimpacted by the treatment that will impact the outcome.
12 Cognitive Behavior Therapy Thoughts Beliefs Cognitions Self-Talk Cognitive Behavioral Actions Behavior Observable Activities Emotional Physiological Feeling Mood Emotions Biology Genetics Environmental
13 Application of CBT SIC Model Involves Educating and Helping Patients to Develop: Skills for modifying beliefs Identifying distorted thinking, or beliefs Changes behaviors
14 Cognitive Behavioral Therapy Cognitive Model of Emotional Response Psychotic Symptoms Thoughts Feelings Behaviors Situations Events Cognitive Behavioral Benefit Modifying the content of our thoughts that determine what type of emotions we feel Biological Psychosocial Vulnerability Model CBT takes as its primary focus the dysfunctional experiences Event Thought Feeling Actions Results
15 Cognitive Behavioral Therapy Cognitive i Model of Emotional lr Response Psychotic Symptoms Thought Cognitive Behavioral Emotion Behavior Biological Psychosocial Vulnerability Model 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.
16 Cognitive Behavioral Therapy Stress Vulnerability Model Zubin and Spring (1977) Psychotic Symptoms Cognitive Behavioral Biological Psychosocial Vulnerability Model In the case of patients diagnosed d with PDP Genetic predisposition Alternative environmental factors
17 Cognitive Behavioral Therapy Stress Vulnerability Model Zubin and Spring (1977) Psychotic 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). Cognitive Behavioral As a result, antipsychotic drug treatment is often used to manage persistent and troublesome psychotic symptoms in PD patients. Biological Psychosocial Vulnerability Model There is no FDA pharmacological treatment approved for PDP in the United Stated or 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.
18 Methodology Dominican Republic Participants Methodology Participants in this study were recruited from the medical center Fundacion Activo Inc. in Santo Domingo Este in the Dominican Republic. 50% The study was conducted with a total of five patients (n=5) identified with PDP for 30% inclusion in the study. Four patients were male and one female, and all over 65 years of age. All (five) patients where on atypical psychiatric and dopaminergic pharmacological treatment. Porcen ntaje de Encuestados 70% 60% 40% 20% 10% 0% Physical - Family Member 65% (13) 25% %(5) 5% (1) 5% (1) 0% (0) Nothing A little Normal Pretty Extremly
19 Assessments and Measure World Health Organization Quality of Life(WHOQOL) Psychotic Symptoms It assesses the individual's id perceptions in the context of their culture and value systems, and their personal goals, standards and concerns. Cognitive Behavioral Biological Psychosocial Vulnerability Model Instrument comprises 26i items, which h measure the following broad dd domains: physical health, psychological health, social relationships, and environment. 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 a novelty in the PDP population.
20 Assessments and Measure Assessments and Measure Psychotic Symptoms Cognitive Behavioral Biological Psychosocial Vulnerability Model Positive and Negative Syndrome Scale (PANSS) Spanish version. Symptom Checklist-90-Revised (SCL-90-R) Spanish version. World Health Organization Quality of Life Instruments (WHOQOL-BREF) Spanish Diagnostic Statistical Manual 5 (DSM-5) Spanish Edition Mini Mental Status Exam (MMSE)
21 Physical Limitations The Research Psychotic Symptoms The research investigated the experience of people living with PD Managing self Medication in connection Cognitive Behavioral Biological Psychosocial Vulnerability Model Mind Body The study td distinguished i d the quality of life of livingi with PD. Mind-Brain identity in a theoretical perspective is more than a brain state is a mental states, the implication of this study was the event, involved in explaining how the mind emerges from the brain. The mind is an epiphenomenon, with influences on the physical world.
22 Help Individual with Parkinson s Disease and Care Givers Patients worsening of symptoms Correlation Significant Correlation Between Caregiver s burden Depression The presence of PD and its chronicity significantly increases caregiver burden and decreases the quality of life. However, even mild levels of depression/psychosis increases disability and overall functional impairment progress in tandem with personal care decline. PD has been found to affect the individuals life, as well as their family members. The increasingly worsening states of those with PD make it necessary to provide patient care and support. Usually, the role of family members in Dominican Republic, especially the patient s partner. In this investigation we found that there is a relation between the seriousness of the motor symptoms and non-motor symptoms specifically, depression in patients diagnosed with PD and a correlation of the burden on caregivers. Motor symptoms Relation Non-Motor symptoms
23 File PANSS Scale System Positive Scale 6 5 NUMBER OF RES SPONDENTS Absent Minimal mild Moderate Moderate Severe Severe Extreme Delusions Conceptual Disorganisation Hallucinatory Behaviour Excitement Grandiosity Suspiciousness/persecution Hostility
24 File PANSS Scale System Positive Scale Number of Respon ndents Hostility Excitation ABSENT MINIMAL MILD MODERATE Delusions Delusions Disorganization Conceptal Hallucinations Behavior Excitation Grandiosity Mistrust / Persecution Hostility
25 PSYCHOLOGICAL - PT Psychological Symptoms Tenth Week Improvement Psychological Symptom 60% Psychological Symptoms 55% (11) 25 Tenth Week Improvement Psychological Symptoms 120% 50% 45% (9) % Porcenta aje de Encuestados 40% 30% 20% 10% % 60% 40% 20% 0% A little Modorate 0 Moderate Normal Total Series1 Series2 0%
26 Psychological -FM Psychological Symptoms Psychological Symptoms Psychological Symptoms Psychological Symptoms 45% 44% (7) 45% 42% (10) 40% 40% Porcentaje e de Encuestados 35% 30% 25% 20% 15% 25% (4) 31% (5) Porcentaje e de Encuestados 35% 30% 25% 20% 15% 29% (7) 25% (6) 10% 10% 5% 5% 4% (1) 0% Nothing A little Moderat 0% Nothing A little Moderat Pretty
27 PHYSICAL HEALTH - PT 90% 84% 80% 70% Percen ntage of Respondents 60% 50% 40% 30% 52% 22% Series1 Series2 20% 15% 12% 11% 10% 0% 4% 0% Nothing A little Moderate Much Extreme
28 PHYSICAL HEALTH - FM Physical - Family Member Physical - Family Member Physical - Family Member Physical - Family Member 70% 65% (13) 60% 57% (12) 60% 50% Porcen ntaje de Encuestados 50% 40% 30% 20% 25% (5) Porcen ntaje de Encuestados 40% 30% 20% 14% (3) 29% (6) 10% 5% (1) 5% (1) 10% 0% 0% (0) Nothing A little Normal Pretty Extremly 0% 0% (0) 0% (0) Nothing A little Normal Pretty Extremly
29 Social Relationship - FM Quality of Life Measure Social Relationship Social Relationship 40% 35% 33% (10) 37% (11) 70% 63% (19) Porcenta aje de Encuestados 30% 25% 20% 15% 10% 23% (7) 7% (2) Porcentaje de Encuestados 60% 50% 40% 30% 20% 37% (11) 5% 10% 0% very Insastifecho/a Insastifecho/a Normal pretty Satifecho/a 0% The normal Normal
30 Quality of Life Measure Social Relationship Social Relationship Social Relationships Social Relationship 50% 46% (16) 46% (16) 50% 45% 49% (20) 46% (16) 46% (16) 41% (17) Percenta age of Respondents s 45% 40% 35% 30% 25% 20% 15% 10% 9% (3) Porcentaje de Encue estados 40% 35% 30% 25% 20% 15% 10% 5% 0% 9% (3) 5% (2) 2% (1) 2% (1) 0% (0) 0% (0) Series 1 Series 2 5% 0% very Insastifech/a Insastifech/a Normal
31 Family Dominican Cultural Practice La Familia & La Casa Identity The four wives wves of the patients that Sources of value and participated in the investigation assisted support to their spouses diligently and with Dominican Families responsibility in theirrole as caregiver. Family Support The only female patient in this study did not have family support, and no significant We recognized that Dominican s value improvement was noted. The family la their families and identify their familia familia has a sense of responsibility that as a source of identity and support in times of crisis. leads to volunteerism that the house la casa is the center of care.
32 Conclusion Conclusion & Recommendations In this study, the researchers took several measures to ensure the most accurate results were obtained and the objectives of the study were achieved. In the country there was no available statistics that can be used to quantify the PD population, pp the prevalence PD is hard to know. This study found that hallucinatory phenomena in PD are more frequent than have been described in previous studies.
33 Questions?
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