Final self reflection
Nn-
MH708IndivPresent--InterpersonalTherapy.pptx
MH708: Interpersonal Therapy
Week 4
July 28 at 8am E
Section 1: Interpersonal Therapy Description
3 Learning Objectives:
Understand the core principles, psychiatric APRN practice applications, and synthesized research about interpersonal therapy (IPT).
Peer-to-peer learning about evidence-based interpersonal therapy using a leadership-approach seminar.
Critical evaluation and application of advanced knowledge of IPT to promote person-centered care.
Brief historical summary:
Who: "Dr. Gerald Klerman joined by Dr. Eugene Paykel at Yale University (Weissman, 2020)."
When: Weissman (2020) discusses that IPT was developed and tested in a 1969 study as a maintenance treatment for ambulatory nonbipolar depression.
Why: Markowitz and Weissman (2012) describe the beginnings of IPT as an experimental research to test the relative efficacy of a tricyclic antidepressant, with/without psychotherapy, for patients with major depressive disorder.
Section 1: Interpersonal Therapy Description
Theory/Model Critique:
Major concepts/components: Wheeler (2020) describes the guiding principles of IPT as treatment of 3 primary aspects of depression [However, IPT actively addresses #1-2, but the 3rd source is generally deep seated and originates in unconscious/implicit memory (Wheeler, 2020)]:
Symptom function: how depressive affect and neurovegetative signs and symptoms are affecting the patient personally and in relationships with others (Wheeler, 2020).
Social and interpersonal relations: how a person interacts with others, based on early childhood experiences, current social reinforcement, and the sense of mastery (Wheeler, 2020).
Personality and character problems: characterological traits, such as pessimism, poor self-esteem, resentment, and poor communication with others (Wheeler, 2020).
“Sessions[S] #1-4 are initial intake/assessment phase where the therapist/patient deal with the depression; S #5-12 are middle/active treatment phase where goals are identified, treatment focus is agreed on, strategizing to address concerns; S #14-16 are final/ termination phase that focuses on the ending of treatment/grief of loss of therapy/therapist (Wheeler, 2020).”
Section 1: Interpersonal Therapy Description
Theory/Model Critique:
Complexity: “IPT seems simple as it is a focused, time-limited psychotherapy; not a causal explanation for depression, but a pragmatic treatment for it (Wheeler, 2020).”
Scope: “IPT is considered middle-range theory, as it is not as abstract as grand theory but is more focused than a conceptual model (Markowitz & Weissman, 2012).”
Usefulness: “It can help guide the psychiatric APRN practice by structuring the framework in a practical way to understand the treatment of mood disorders, depression, interpersonal issues like grief, role transitions, interpersonal disputes, and social deficits (Markowitz & Weissman, 2012).”
Section 1: Interpersonal Therapy Description
Techniques for use:
“Assessment phase, first stage: conduct interpersonal inventory and completion of timeline. Review key people/relationships in the patient's life to identify patterns of conflict, loss, and support (Markowitz & Weissman, 2012).”
Then negotiation of which IPT problem area should be the focus of treatment (Wheeler, 2020).
Communication analysis that examines past experiences and interactions; the goal is to improve communication skills to reduce misunderstandings (Markowitz & Weissman, 2012).
Role-playing to practice new communication techniques and strategies for effective emotional expression in a setting where the patient feels safe (Markowitz & Weissman, 2012).
Clarification/encouragement of affect to help the patient express their emotions and understand their personal role in their interpersonal challenges (Markowitz & Weissman, 2012).
Problem-solving where the patient and therapist collaborates on strategies to manage interpersonal disputes, role transitions, grief or interpersonal deficits (Markowitz & Weissman, 2012).
Section 1: Interpersonal Therapy Description
Evidence-based literature to support utilization of theory/model in specific populations
Murphy et al. (2012)'s randomized controlled trials [RCT] provide strong evidence supporting interpersonal psychotherapy for eating disorders [ED]; IPT is as effective as CBT for long-term treatment of bulimia nervosa, binge eating disorder, and reducing eating disorder behaviors by improving interpersonal functioning.
Murphy et al. (2012) discusses IPT has both structured but flexible framework, often adapted for various populations like those with complex histories or behavioral intervention resistance; IPT targets IP problems as part of the cause or maintaining factor of eating disorders, thus treating any of the 4 underlying psychological triggers that are common in ED patient populations (triggers like grief, loss, role disputes, social isolation). RCTs evidenced significant improving in eating habits/pathology and co-occurring depression after IPT sessions terminated (Murphy et al., 2012). IPT is a viable first or second-line treatment in patients with eating disorders (Murphy et al., 2012).
Section 1: Interpersonal Therapy Description
Lifespan issues: According to Young et al. (2018), IPT is indeed adaptable across the lifespan; For adolescents and younger populations, IPT does require some developmental modifications
Interpersonal Psychotherapy for Adolescents (IPT-A) or IPT-Adolescent Skills Training (IPT-AST) is modified and designed for depressive symptoms in youth (Young et al., 2018); this focuses on common adolescent stressors like peer conflict, family roles or social transitions.
Young et al. (2018) found that although IPT-AST significantly improved adolescent depressive symptoms in the short-term, the effects diminished in 12-24 months if not reinforced; thus, IPT-AST should be accompanied by ongoing support or booster sessions.
Cultural variations: Grote et al. (2009) made specific cultural modifications that enhanced the adaptability, relevance and effectiveness of IPT across different populations.
Grote et al. (2009) successfully adapted IPT for culturally diverse groups i.e. Latinx, Asian, Black, refugee and immigrant populations; modifications emphasized on family/community roles, sensitivity to: assimilation stress, migration/refuging trauma, intergenerational conflict, language availability, role transitions/expectations in new communities, cultural dislocation or social stigma.
Section 2: Practice Application of IPT
Chosen psychiatric population: IPT for youth with eating disorders
Chosen disorder: Binge-Eating Disorder [BED] Diagnostic Criteria F50.81 (American Psychiatric Association, 2022).
Epidemiology:
Incidence: Limited precise data on this, but data estimates about 0.2% to 0.5% of the US develops BED yearly (Hudson et al., 2007).
Prevalence: “According to two U.S. epidemiological studies conducted in community samples, the 12-month prevalence of binge-eating disorder ranges from 0.44% to 1.2%, with rates two to three times higher in women than in men (0.6% to 1.6% in women[W]; 0.26% to 0.8% in men[M]), & the lifetime prevalence ranges from 0.85% to 2.8% (1.25% to 3.5% in W; 0.42% to 2.0% in M) (APA, 2022).”
Demographics: More common in females, but men are also affected; typical onset in late teens to early 20s; ranges from adolescence to adulthood (Hudson et al., 2007).
Section 2: Practice Application of IPT
Assessment
Screening tests/measures: Eating Disorder Examination Questionnaire (EDE-Q), Binge Eating Scale (BES), SCOFF Questionnaire, meeting DSM-5-TR Criteria during Clinical Interview (Fairburn & Beglin, 2008).
Clinical presentation: recurrent episodes of binge eating, like eating discreetly and a larger amount than most people would eat; feeling lack of control during episodes; BED must have 3 or more--eating more rapidly than normal; eating until uncomfortably full; eating large amounts when not hungry; eating alone due to embarrassment; feeling disgusted/depressed/guilty afterward; marked distress about binge eating; occurs 1+ times/week x 3 months; no compensatory behaviors (APA, 2022).
Typical age of onset: late teens to early 20s but can also occur in adolescence or later adulthood (APA, 2022).
Section 2: Practice Application of IPT
Cultural variations of clinical presentation and potential impact on treatment
Differing cultural attitudes toward food and body image, such as in some cultures, large meals or emotional eating are perceived as normal/celebratory behavior, leading to underreporting of these cases (Guerdjikova et al., 2017).
Many cultures have stigma against mental health which can often delay care as patients do not feel empowered to seek help until it leads to somatic presentation like stomach pain/weight loss (Guerdjikova et al., 2017).
Gender norms make it less likely for males to report symptoms due to stigma or lack of knowledge (Guerdjikova et al., 2017).
Lack of culturally adapted tools means language barriers can hinder patients from seeking help and communicating their distress (Guerdjikova et al., 2017).
Assimilation stress can cause binge eating related to stress, loss of tradition or identity conflict (Guerdjikova et al., 2017).
Section 2: Practice Application of IPT
DSM-5-TR: Binge-Eating Disorder Diagnostic Criteria F50.81 (American Psychiatric Association, 2022).
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period (e.g., within any 2-hour period), an amount of food that is larger than what most people would eat in a similar period under similar circumstances.
2. A sense of lack of control over-eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during bulimia nervosa or anorexia nervosa.
Specify if:
In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average frequency of less than one episode per week for a sustained period.
In full remission: After full criteria for binge-eating disorder were previously met, none of the criteria have been met for a sustained period.
Specify current severity:
The minimum level of severity is based on the frequency of episodes of binge eating (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.
Mild: 1–3 binge-eating episodes per week. Moderate: 4–7 binge-eating episodes per week. Severe: 8–13 binge-eating episodes per week. Extreme: 14 or more binge-eating episodes/week.
Section 2: Practice Application of IPT
Natural course of binge-eating disorder [BED]:
Onset: typically, late adolescence or early adulthood, usually after high stress triggers or dieting periods; onset can also happen in midlife ages, significantly in patients with chronic body dysmorphia or past traumatic experiences (APA, 2022).
Course: BED tends to be chronic but can fluctuate; episodic remissions and relapses are common; not associated with compensatory behaviors (e.g., purging, excessive exercise), while anorexia and bulimia typically are (APA, 2022).
Prognosis: overall, better than bulimia/anorexia; high comorbidity with mood/anxiety/substance use disorders that tends to lead to negative outcomes, especially if untreated (APA, 2022).
Differentials:
Obesity, bipolar disorder binge eating during manic episodes, major depressive disorder, borderline personality disorder (APA, 2022).
Section 2: Practice Application of IPT
IPT Treatment of Binge Eating Disorder [BED]:
Efficacy: IPT has been found to be just as effective as Cognitive Behavioral Therapy (CBT) for reducing binge-eating episode frequency and long-term improvement of psychological distress; CBT yields faster results for lessening BED symptomology, but IPT has demonstrated more remission sustainability for patients with struggling with interpersonal difficulties (Wilson et al., 2010).
Per the RCT done by Wilfley et al. (2002), they found strongly comparable evidence that IPT is as effective as CBT; they also found that IPT was more effective than reducing binging episodes through behavioral weight loss alone, evidenced by longer improvements seen at the patients' 1-year follow up; IPT might even prove more effective/useful for patients who did not have the desired response to CBT or for patients who have IP stressors as their key triggers.
Alternative strategies: While CBT is the gold standard for BED, Dialectical Behavior Therapy (DBT) can help with emotional regulation/distress tolerance; Behavioral Weight Loss (BWL) helps with diet restraint/weight control, but it is less effective for psychological presentation (Fairburn & Beglin, 2008).
Treatment evidence: IPT demonstrates lasting improvements in BED and its related psychosocial functioning, so it is best suited for BED with IP role disputes, grief, role transitions as key triggers (Fairburn & Beglin, 2008). Manual adaptations of IPT for BED have been developed and validated by Wilson et al. (2010).
Section 3: Synthesized research
Compare & contrast IPT with CBT for Binge-Eating Disorder
While CBT is first-line treatment for BED, IPT for BED shows lower remission rates and faster treatment speed; RCT of 130 participants, BMI range 17.5-40, while CBT achieved remission in ~66% of patients vs ~33% for IPT after treatment was terminated, but at 60-week follow up, CBT remission rose to only 69% while IPT remission rates rose to 49% (Fairburn et al., 2009).
IPT is significantly effective in special populations such as in individuals with high negative affect or high IP stressors, even outperforming self-help CBT approaches (Guerdjikova et al., 2017).
PMHNPs should choose modality based on client's needs and clinical implications; CBT remains first-line where immediate results are needed in behavioral change/cognitive restructuring; IPT can be a valuable alternative for patients with significant IP distress/poor self-esteem/poor CBT response (Xie et al., 2021).
Section 3: Synthesized research
Potential unintended consequences/potential harm if used incorrectly, risks vs benefits:
CBT Benefits: Gold-standard treatment for BED, strong evidence for reducing binging frequency, ED and depressive symptomology (Smith et al., 2023).
IPT Benefits: targets underlying IP vulnerabilities like role disputes, grief, or social deficits contributing to binge eating episodes (Murphy et al., 2012).
CBT Risks: adolescents still developing executive functioning may have trouble with treatment adherance and persistent loss of control eating, even with high CBT attendance (Smith et al., 2023).
IPT Risks: limited IPT evidence in teens; thus, applying unmodified/non-developmentally adapted adult IPT poses risk of missing evidence in the youth population (Goldschmidt et al., 2024).
Harmful CBT: when used in youth with impaired motivation/delayed development/executive dysfunction; if patient feels revictimized by structured food monitoring or if binging is caused by an underlying trauma (Goldschmidt et al., 2024).
Harmful IPT: if used in youth cases of acute/severe BED who need immediate relief from interventions; or if used in cases where IP conflict is not a main factor in the binge eating pattern (Smith et al., 2023).
References page 1:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
Fairburn, C. G., & Beglin, S. J. (2008). Eating Disorder Examination Questionnaire (EDE-Q 6.0). In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating disorders (pp. 309–313). Guilford Press.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2009). Transdiagnostic cognitive‐behavioral therapy for patients with eating disorders: A two‐site trial with 60‐week follow‐up. American Journal of Psychiatry, 166(3), 311–339.
Goldschmidt AB, Jeong K, Yu L, Egbert AH, Schmidt R, Hilbert A. (2024). Executive functioning and treatment outcome among adolescents undergoing cognitive-behavioral therapy for binge-eating disorder. J Child Psychol Psychiatry, 66(1):64-74. https://doi.org/10.1111/jcpp.14031
Grote, N. K., Swartz, H. A., Geibel, S., Zuckoff, A., Houck, P. R., & Frank, E. (2009). A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression. Psychiatric Services, 60(3), 313–321. https://doi.org/10.1176/ps.2009.60.3.313
Guerdjikova, A. I., Mori, N., Casuto, L. S., & McElroy, S. L. (2017). Binge eating disorder. Psychiatric Clinics, 40(2), 255–266. https://doi.org/10.1016/j.psc.2017.01.003
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358. https://doi.org/10.1016/j.biopsych.2006.03.040
Markowitz, J. C., & Weissman, M. M. (2012). Interpersonal psychotherapy: Past, present and future. Clinical Psychology & Psychotherapy, 19(2), 99–105. https://doi.org/10.1002/cpp.1774
Murphy, R., Straebler, S., Basden, S., Cooper, Z., & Fairburn, C. G. (2012). Interpersonal psychotherapy for eating disorders: current perspectives. Clinical Psychology & Psychotherapy, 19(2), 150–158. https://doi.org/10.1002/cpp.1780
References page 2:
Smith, K.E., Goldschmidt, A.B. (2024). Treatment of Binge-Eating Disorder Across the Lifespan: An Updated Review of the Literature and Considerations forFuture Research. Current Obesity Report 13(2), 195–202. https://doi.org/10.1007/s13679-024-00553-4
Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2018). The guide to interpersonal psychotherapy: Updated and expanded edition. Oxford University Press.https://doi.org/10.1093/med-psych/9780190695975.001.0001
Weissman, M. M. (2020). Interpersonal psychotherapy: History and future. The American Journal of Psychotherapy, 73(1), 3–7. https://doi.org/10.1176/appi.psychotherapy.20190032
Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of General Psychiatry, 59(8), 713–721. https://doi.org/10.1001/archpsyc.59.8.713
Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological treatments of binge eating disorder. Archives of General Psychiatry, 67(1), 94–101. https://doi.org/10.1001/archgenpsychiatry.2009.170
Wheeler, K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing Co., LLC.
Young, J. F., Mufson, L., Gallop, R., & Eberhart, N. K. (2018). Interpersonal psychotherapy–adolescent skills training: Effects on school and social functioning. School Mental Health, 10(3), 241–252. https://doi.org/10.1007/s12310-018-9262-6
Xie, Q., Zhang, K., Fan, C., Liu, J., & Liu, T. (2021). The effectiveness of interpersonal psychotherapy versus cognitive behavioral therapy for eating disorders: A systematic review and meta-analysis. Clinical Psychology & Psychotherapy, 29(2), 494–507. https://doi.org/10.1002/cpp.2632
