Overview of psychotherapiesEVIDENCE-BASED PSYCHOTHERAPIES Cognitive and behavioral psychotherapies●Psychodynamic psychotherapy●Interpersonal psychotherapy●Motivational interviewing

Cognitive and behavioral therapies — Cognitive and behavioral therapies can be used individually or in combination as a program of interventions known as cognitive behavioral therapy or CBT. CBT often includes education, relaxation exercises, coping skills training, stress management, or assertiveness trainingIn cognitive therapy, the therapist helps the patient identify and correct distorted, maladaptive beliefs. Behavioral therapy uses thought exercises or real experiences to facilitate symptom reduction and improved functioning. This may occur through learning, through decreased reactivity from repeated exposure to a stimulus, or through other mechanisms.Cognitive behavioral therapy is an evidence-based treatment for psychiatric disorders including depression, generalized anxiety disorder, post-traumatic stress disorder, panic disorder, eating disorders, and obsessive compulsive disorder, as well as several medical conditions (eg, insomnia, smoking, low back pain).Psychodynamic psychotherapy — Psychodynamic therapy primarily relies on developing patient insight [4]. Psychodynamic psychotherapy is based upon the idea that childhood experiences, past unresolved conflicts, and previous relationships significantly influence an individual’s current situation in life. Adult relationships are understood to be a byproduct of unconscious patterns that begin in childhood. Psychodynamic psychotherapy uncovers the unconscious patterns of interpersonal relationships, conflicts, and desires with the goal of improved functioning [5].

Psychodynamic therapy is used for some psychiatric disorders, including depression, anorexia nervosa, and personality disorders. 

Interpersonal psychotherapy — Interpersonal therapy (IPT) addresses interpersonal difficulties that lead to psychological problems [6]. Interpersonal psychotherapy focuses on the individual’s interpersonal life in four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits.

Interpersonal therapy is an evidence-based treatment for some psychiatric conditions, including depression, bipolar disorder [7], and eating disorders.

Motivational interviewing — Motivational interviewing is a type of psychotherapy that is used in primary care and mental health care to encourage patients to change maladaptive behaviors [8]. Derived from cognitive-behavioral and readiness-to-change models, motivational interviewing seeks to help patients recognize and make changes to these behaviors, matching strategies to the patient’s stage of readiness to change. Key elements of motivational interviewing include:

●Expressing empathy●Helping the patient identify discrepancies between his or her problematic behaviors and broader, personal values●Expecting the patient to resist change and accepting it●Enhancing the patient’s self-efficacy (ie, confidence in his or her capability to surmount obstacles and successfully change)

 The use of motivational interviewing is growing, and has been applied to the treatment of substance use disorders, promoting lifestyle changes (eg, weight reduction, smoking cessation), and encouraging adherence to complex medical treatments (eg, heart failure self-management). OTHER PSYCHOTHERAPIES — Other psychotherapies that are widely used vary in approach from one therapist to the next. Their efficacy has not been systematically studied.

Supportive psychotherapy — Supportive psychotherapy or counseling is widely used in medical practice, eg, to help individuals cope with illness, deal with a crisis or transient problem, and maintain optimism or hope [9]. Techniques vary but most models emphasize communication of interest and empathy; supportive therapy may also include guidance on available services, advice, respect, praise, and/or encouragement. The efficacy and administration of supportive psychotherapy for depression is discussed separately. 

Eclectic or integrative psychotherapy — In surveys of mental health clinicians in the US and Canada, a majority of clinicians (psychiatrists, psychologists, social workers, and others) identified themselves as practicing an eclectic or integrative form of psychotherapy [10,11]. Eclectic and integrative therapists draw concepts and techniques from a variety of different types of therapy, including psychodynamic, cognitive, and behavioral approaches

FORMAT OF PSYCHOTHERAPYThere is generally no single preferred format, although there is evidence that some problems respond better or worse to different configurations. As an example, the preponderance of clinical experience and study data indicate that couple therapy is useful for marital problems [13]. Group therapy for adolescents with problem behavior may result in increased delinquency, whereas group therapy may be helpful for adults with a substance use disorder

 For patients with schizophrenia and bipolar disorder, family psychoeducation helps family members learn about the disorder, solve problems, and cope more constructively with the patient's illness

The majority of patients receiving treatment for a psychiatric disorder in the US receive this treatment in primary care rather than in the mental health specialty sector. -------------------------------------------------------------------------------------------------------------

GADWe recommend first-line treatment of generalized anxiety disorder (GAD) with either a serotonergic antidepressant or cognitive behavioral therapy (CBT) (Grade 1A). Both interventions have been found to be efficacious compared to placebo; they have not been compared in head to head trials.When medication is used to treat GAD, we recommend selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) as first-line medication treatment rather than other medications (Grade 1C). In cases of co-occurring GAD and depression, a common comorbidity, SSRIs, or SNRIs can provide effective treatment for both disorders.Among patients with a good clinical response to an SSRI or SNRI in GAD, we recommend continuing the medication for at least 12 months, rather than the 6 months supported by previous researchSecond-line medications for GAD that is nonresponsive to SSRIs and SNRIs include tricyclic antidepressants (TCAs), benzodiazepines, and pregabalin.Benzodiazepines are effective for acute and long-term treatment of GAD, but should generally be reserved for patients without a history of substance abuse. They may also be useful for acute symptoms during the period before an SSRI takes effect, or as an adjunct for partial responders to SSRIs or SNRIs Other interventions used for treatment-resistant GAD, either as monotherapy or in augmentation of SSRIs, include CBT, mirtazapine, and quetiapine.

We suggest treatment of GAD with CBT rather than nondirective supportive therapy or psychodynamic therapy (Grade 2B) or other psychotherapies.

CBT addresses the various cognitive, behavioral, and physiological features of GAD through a number of strategies. First, overestimations and catastrophizing of negative events are addressed through cognitive skills that encourage evidence-based thinking, which in turn is believed to lessen attentional biases to threat. Deficits in problem solving are targeted through additional cognitive skills that encourage a problem-coping focus, as well as behavioral skills for enhanced decision making and time management. Behavioral practices

aim to reduce excessive checking, procrastination, and other ‘worry’ behaviors, and often include repeated exposure to anxiety-provoking situations. In addition, through repeated exposure to catastrophic images, the emotional response and autonomic arousal subsides, which in turn reduces the drive to shift to excessive worry to avoid such images. Finally, progressive muscle relaxation aims to reduce excessive muscle tension and vigilance to threat.

Specific techniques Education — Treatment begins with education on:

●Informing and correcting misconceptions regarding anxiety, worry, and associated symptoms●Causative factors of pathological worry and anxiety●A model of factors that perpetuate GAD●The treatment plan and rationale (ie, symptoms of GAD will subside by using evidence-based and coping oriented thinking, by dealing directly with anxiety provoking images and situations, and by learning to relax)

Self-monitoring — Self-monitoring is introduced in the first treatment session and continues throughout the entire treatment. Learning to observe their reactions from an objective standpoint encourages the patient’s development as a personal scientist and increases his or her accuracy in self-observation. Self-monitoring allows patients to chart their progress in therapy.

Patients keep track of significant episodes of worry on a Worry Record (form 1) to be completed as soon as possible during or after each worry episode. The record provides a description of the cues, maximal distress, and symptoms, thoughts, and behaviors. Patients additionally complete a daily mood record at the end of each day to record overall or average levels of anxiety.

Relaxation training — Relaxation training can be particularly meaningful for GAD patients as they often experience elevated muscle tension and reduced flexibility of autonomic functioning [36]. Relaxation training consists of progressive muscle relaxation (after brief deliberate tension) [37] of all muscle groups of the body in a systematic manner, beginning with 16 muscle groups, and then condensing to 8 muscle groups, and 4 muscle groups.Cognitive restructuring — Cognitive restructuring is a set of skills for identifying and modifying misappraisals that contribute to anxiety, including:

●Patients are shown how anxiety and maladaptive behaviors are generated by overly-negative interpretations of events.●Patients are helped to identify errors in thinking (eg, overestimating the probability or valence of negative events) and rigid rules or beliefs that underlie dysfunctional thought patterns.●Patients are encouraged to use an empirical approach to examine the validity of thoughts by considering all of the available evidence.

Imagery exposure — Imagery exposure is designed to help patients tolerate negative affect and autonomic arousal associated with fearful images that they often attempt to avoid through worry [38]. Patients generate hierarchies of fear images related to two or three main areas of worry and are led through systematic exposure to these images. When anxiety elicited by an image is reduced to a mild level, then patients progress to the next image on the hierarchy.Exposure to anxiety-provoking situations — This technique involves repeated exposure to situations that are avoided or engaged in with excessive preparation or checking. Patients generate a hierarchy of situations or activities. Examples include allowing children to have sleep overs, family vacations, arriving on time (instead of excessively early) at scheduled appointments, taking on responsibilities, or saying ‘no’ to requests.

OCDWe recommend that patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT), a selective serotonin reuptake inhibitor (SSRI) medication, or both (Grade 1A).●For most patients with OCD, we suggest first-line treatment with exposure and response prevention (a type of CBT) rather than treatment with an SSRI medication (Grade 2B). SSRI medication is a reasonable alternative if CBT is unavailable, not indicated, or if the patient prefers medication. ●For patients with OCD and a severe, co-occurring disorder that is typically responsive to SSRI treatment, we suggest initial treatment of both disorders with an SSRI

If an adequate trial of the SSRI results in no response, we suggest treatment with a different SSRI, clomipramine, or venlafaxine.

If a trial of an SSRI or SNRI results in a partial response, but the patient continues to experience clinically significant symptoms, we suggest augmenting the antidepressant with CBT before trying an

antipsychotic medication (eg,   risperidone   0.5 to 3   mg/day)   (Grade 2B). Other approaches with less supporting evidence are increasing the SSRI dose above the maximum approved by the FDA or adding clomipramine (≤75 mg/day). (See 'Augmentation' above.)●SSRIs and clomipramine generally lead to improvement in 40 to 60 percent of people with OCD. When patients have an adequate response, practice guidelines recommend that they be maintained on the medication for at least one to two years, though more research is needed on this issue.CBT for OCD typically includes: patient and family education, cognitive restructuring, exposure therapy, and response prevention. (See 'Therapy' above.)•Cognitive restructuring addresses strongly held, mistaken beliefs about obsessional thoughts. Patients are helped to interpret their obsessional thoughts as normally occurring intrusions, rather than personally meaningful or threatening images and ideas that need to be controlled or suppressed.•Exposure and response prevention involves repeated and prolonged exposure to situations that provoke obsessional fear along with abstinence from compulsive behaviors, allowing the patient to learn that these situations are not harmful and that their anxiety will subside.

Major depressionMild to moderate major depression

●Mild to moderate unipolar major depression is marked by the absence of suicidal or homicidal ideation or behavior, or the presence of suicidal or homicidal ideation that does not pose an imminent risk; in addition, patients manifest no psychotic features, little to no aggressiveness, and intact judgement.●For the initial treatment of mild to moderate unipolar major depression, we suggest pharmacotherapy plus psychotherapy, rather than pharmacotherapy alone or psychotherapy alone (Grade 2B.•For patients with mild to moderate unipolar major depression who are initially treated with antidepressants, we suggest selective serotonin reuptake inhibitors (SSRIs) rather than other antidepressants (Grade 2B). However, serotonin-norepinephrine reuptake inhibitors, atypical antidepressants, and serotonin modulators are reasonable alternatives. Tricyclic antidepressants and monoamine oxidase inhibitors are typically not used as initial treatment because of concerns about safety and adverse effects (table 4).•Several psychotherapies are available to treat unipolar major depression. For patients with mild to moderate unipolar major depression who are initially treated with psychotherapy, we suggest cognitive-behavioral therapy (CBT) or interpersonal psychotherapy rather than other psychotherapies (Grade 2C). However, reasonable alternatives to CBT and interpersonal psychotherapy include family and couples therapy, problem solving therapy, psychodynamic psychotherapy, and supportive psychotherapy.

Among patients with mild to moderate unipolar major depression who start antidepressants, improvement is often apparent within two weeks.● We generally treat mild to moderate unipolar major depression for 6 to 12 weeks before deciding whether antidepressants have sufficiently relieved symptoms. However, for patients who show little improvement (eg, reduction of baseline symptoms ≤25 percent) after 4 to 6 weeks, it is reasonable to administer next-step treatment.

Severe major depression

●Severe unipolar major depression is marked by suicidal or homicidal behavior or ideation with a specific plan and intent, psychotic features, catatonia, poor judgement, and/or grossly impaired functioning.

●For patients with severe unipolar major depression, we suggest initial treatment with pharmacotherapy plus psychotherapy, rather than other treatment regimens (Grade 2B). However, a reasonable alternative is pharmacotherapy alone or electroconvulsive therapy (ECT). For patients with severe suicidality or malnutrition secondary to food refusal, we suggest ECT as initial treatment rather than other treatment regimens.

For patients with persistent depressive disorder (Dysthymia), we suggest antidepressants plus psychotherapy rather than antidepressants alone or psychotherapy alone 

PTSDPharmacotherapy for posttraumatic stress disorder in adultsWe recommend treatment of PTSD with a trauma-focused cognitive-behavioral therapy (CBT), medication (a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI)), or a combination of both modalities (Grade 1A). (See "Psychotherapy for posttraumatic stress disorder in adults", section on 'Cognitive and behavioral therapies'.)●We suggest first-line treatment of PTSD with a trauma-focused CBT over medication (Grade 2B). An SSRI or SNRI can be used for first-line treatment in patients who prefer medication to psychotherapy, or when CBT is not availableBased on the absence of other medications that effectively treat patients with persistent PTSD symptoms following SSRI/SNRI treatment, the limited trials available on atypical antipsychotics in this population, and our clinical experience that some patients appear to benefit from these agents, we suggest adjunctive use of an atypical antipsychotic for PTSD symptoms resistant to SSRIs/SNRIs

We suggest treatment with prazosin for patients with PTSD who experience sleep disruption or nightmares (Grade 2B) or other PTSD symptoms.

We recommend treatment of PTSD with exposure therapy (eg, prolonged exposure), with a program that combines exposure therapy and cognitive therapy (eg, cognitive processing therapy), or with eye movement desensitization and reprocessing (EMDR) (Grade 1A). Trials have found these types of psychotherapy to decrease PTSD symptoms compared to control conditions.

Eye movement desensitization and reprocessing — Eye movement desensitization and reprocessing (EMDR) is a form of CBT that incorporates saccadic eye movements during exposure [26].

The technique involves the patient's imagining a scene from the trauma, focusing on the accompanying cognition and arousal, while the therapist moves two fingers across the patient's visual field and instructs the patient to track the fingers. The sequence is repeated until anxiety decreases, at which point the patient is instructed to generate a more adaptive thought. An example of a thought initially associated with the traumatic image might include, “I’m going to die,” while the more adaptive thought might end up as, “I made it through. It’s in the past.”

Trauma-focused CBT for patients with acute stress disorder has been shown to be efficacious in reducing the likelihood of subsequent development of PTSD. (See"Treatment of acute stress disorder", section on 'Efficacy'.)

Panic disorderPharmacotherapy for panic disorder

We recommend initial treatment of panic disorder with an antidepressant, cognitive behavioral therapy (CBT), or a combination of the two.

When medication is used to treat panic disorder, we suggest first-line treatment with a selective serotonin reuptake inhibitor (SSRI) 

For patients with severe panic disorder and associated disability that has either not responded to an SSRI or SNRI, or cannot wait for the time required for them to work, we suggest treatment with a benzodiazepine over other medications

A long acting benzodiazepine can also be used in conjunction with a serotonergic antidepressant in the first weeks of treatment, before the antidepressant takes effect, in patients with marked distress or impairment. (Bridge)

The duration of pharmacotherapy should be at least one year after symptom control has been attained.Specific techniques comprising CBT typically include education, self-monitoring, breathing retraining, muscle relaxation, cognitive restructuring, exposure, and relapse prevention. (See 'Specific techniques' above.)

Breathing retraining — Breathing retraining is a commonly used somatic coping skill [46]. It is supported by evidence of respiratory abnormalities in PD/A possibly due to hypersensitive medullary carbon dioxide (CO2) detectors, resulting in hypocapnia (ie, lower than normal levels of PCO2) [47].

Traditional breathing retraining involves slow, abdominal breathing exercises. However, its value has been questioned in terms of the degree to which it actually corrects hypocapnic breathing

Specific phobia Psychotherapy for specific phobia in adults

We recommend first-line treatment of specific phobia with a cognitive-behavioral therapy (CBT) that includes exposure treatment over other psychotherapeutic or pharmacologic interventions (Grade 1B). ●We suggest medication treatment of specific phobia when CBT with exposure is unavailable or when patients prefer medication to psychotherapy (Grade 2C). ●For specific phobia with a phobic stimulus that is frequently encountered and feasible to treat with in vivo exposure therapy, we suggest in vivo exposure rather than imaginal or virtual-reality exposure (Grade 2B). (See 'Types of exposure' above.)●For specific phobia with a phobic stimulus that is relatively infrequent (eg, storm phobia) or that would be costly to experience (eg, flying phobia), we suggest treatment with imaginal exposure. This could be enhanced with virtual reality exposure if it is available (Grade 2C). (See 'Types of exposure' above.)●Other cognitive, behavioral, and anxiety management interventions have been tested in combination with exposure treatment, but the evidence for these multi-modal treatments in specific phobia is limited.

When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with an infrequently encountered phobic stimulus with a benzodiazepine.When CBT/exposure is unavailable or when patients prefer medication to psychotherapy, we suggest treatment of specific phobia with a frequently encountered phobic stimulus with a selective serotonin reuptake inhibitor (SSRI).

Complicated griefComplicated grief in adults: Treatment

Complicated grief is a type of acute grief that is unusually prolonged, intense, and disabling; as such, complicated grief is a unique and recognizable mental disorder. For patients with complicated grief, we recommend cognitive-behavioral therapy (CBT) adapted for complicated grief as first-line treatment, rather than other psychotherapies (Grade 1A). We

typically use a form of CBT called “complicated grief therapy.” If patients are not responding to first-line treatment, patients should be re-evaluated with respect to psychosocial problems that require attention. ●Patients unresponsive to CBT specific for complicated grief should be re-evaluated to verify the diagnosis of complicated grief. For patients with an established diagnosis of complicated grief who do not respond adequately to CBT, as well as patients who decline or do not have access to CBT, we suggest behavioral activation as second-line treatment, rather than other treatments.---------------------------------Bereavement is the situation in which a loved one has died, and grief is the distress that occurs in response to bereavement. Although grief can occur in response to other meaningful (non-bereavement) losses, this topic focuses upon grief in response to the death of a loved one.

Acute grief can be intense and disruptive, but usually is integrated over time.●Acute grief typically does not require treatment. For bereaved individuals who do not have mental disorders, we suggest not routinely administering grief counseling or other psychotherapies (Grade 2B). However, grief counseling can be helpful for bereaved individuals who request it, and may also be helpful when it is coupled with other efforts that are focused upon new activities. (See 'Interventions' above.)●For bereaved individuals who do not have mental disorders, we suggest not prescribing psychotropic medications such as benzodiazepines (Grade 2B). ●Support from family, friends, and clergy is usually sufficient to manage the pain of acute grief. Bereaved patients who seek help from clinicians typically can be managed with support, which includes empathic listening, information about the wide range of typical grief symptoms that can occur, reassurance, and monitoring.

 

 SADFor patients with generalized SAD, we recommend first-line treatment with either pharmacotherapy or CBT.For patients with SAD who respond insufficiently to a therapeutic trial of 8 to 12 weeks with an SSRI or SNRI at a maximally tolerated dose, we suggest augmentation with a long-acting benzodiazepine over other medications,We suggest treating performance-only SAD with cognitive behavioral therapy (CBT) rather than medication (Grade 2C). Medication, however, is a reasonable alternative if preferred by the patient or if a therapist trained to provide CBT were not available. 

Summary: GAD, Panic, Bulimia, SAD, OCD (But CBT better) → CBT or SSRI (or both - panic, OCD).MDD: Antidepressant + PsychotherapySpecific phobia, PTSD, performance-only SAD → CBT better than Medications.# UpToDate

Note the similarity between infrequent VS. frequent specific phobia and performance VS. generalized SAD.

Left: Grief!!, adjustment