Dr. Ruzek is associate director of education, Mr. Young is disaster services coordinator, and Dr. Walser is psychologist at the National Center for Posttraumatic Stress Disorder and Veteran’s Affairs Palo Alto Health Care System in Menlo Park, California.

Disclosure: The authors report no financial, academic, or other support of this work.

Please direct all correspondence to: Josef I. Ruzek, PhD, National Center for Posttraumatic Stress Disorder, Education and Clinical Laboratory Division, VA Palo Alto Health Care System, 795 Willow Rd, CA 94025; Tel: 650-493-5000; Fax: 650-617-2769; E-mail: josef.ruzek@med.va.gov.


 

Focus Points

Group treatment of posttraumatic stress disorder (PTSD) can enable helpful comparison with other trauma sufferers and may promote the recognition of the “normality” of posttraumatic reactions.

Education groups focus on helping PTSD survivors understand their experience and familiarize themselves with available treatment options; coping skills training focuses on teaching them how to incorporate the support recovery techniques they learn about.

Repeated exposure to distressing aspects of traumatic memories can help reduce the fear and arousal associated with the trauma, correct faulty perceptions of danger, improve perceived self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of distress.

Group cognitive therapy focuses on educating patients about the relationships between thoughts and emotions, exploring negative thoughts commonly held by trauma survivors, identifying personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking.

 

Abstract

What are the advantages of using group treatment for individuals diagnosed with posttraumatic stress disorder (PTSD) and other trauma-related problems and what are the goals of the different types of group intervention? As one of the most common modes of posttrauma care, groups can be used to provide support, educate participants about PTSD, teach trauma-related coping skills, or facilitate therapeutic exposure and cognitive restructuring. Although research to date is limited, existing evidence suggests that group therapy may be a potentially effective intervention for PTSD. This article outlines several varieties of group intervention, explores issues related to patient selection, and discusses considerations in establishing and managing group services.

 

Introduction

There are several potential advantages to the use of group treatment as a modality in care for trauma survivors with posttraumatic stress disorder (PTSD). First, many trauma survivors feel alone in their experiences. Meeting and sharing with other survivors of a similar trauma can promote a sense of acceptance and belonging. This may be especially useful for those (eg, Vietnam veterans, sexual assault survivors) who encounter negative reactions from others regarding their experience and for whom social alienation may be especially strong. Group treatment enables comparison with other PTSD sufferers and may promote the recognition of the universality of posttraumatic reactions. In addition, they may encourage adaptive functioning through modeling of coping behaviors (eg, self-disclosure) of other survivors. From a provider perspective, group treatment can be cost-efficient in comparison with individual counseling.

Whether these potential benefits of groups render them effective treatments for PTSD is not clear. Very little research has addressed the effectiveness of group treatments for PTSD. In a recent review,1 <20 group psychotherapy outcome studies were located, and only two were randomized-controlled trials. Most existing studies focus on individuals with chronic PTSD, and most have obtained positive treatment outcomes. Evidence, to date, therefore suggests that group treatment is beneficial for those with chronic PTSD, but research in this area is in its infancy and more study is required before the impact of group treatment can be confidently asserted. In particular, there is little research comparing different kinds of group treatments, and no studies comparing group with individual treatment. In addition, little is known about the processes through which group treatments benefit trauma survivors. Despite these limitations of the data, group treatment for PTSD is recommended as “potentially effective” in the International Society for Traumatic Stress Studies (ISTSS) practice guidelines.2

Group interventions for trauma survivors may take many forms. Groups may be used to provide social support, trauma-related education, training in skills for coping with PTSD symptoms and other posttrauma challenges, or opportunity for detailed exploration of traumatic experiences and associated emotions. In the following sections, we review a variety of group alternatives, patient matching considerations, and process issues.

 

Varieties of Group Treatment for Posttraumatic Stress Disorder 

Group Support

Social support is likely one of the most powerful components of group interventions for PTSD. In fact, some group treatments for PTSD focus primarily on providing social support as the primary active ingredient of therapy. There are many reasons why group support is indicated for trauma survivors with PTSD. Many of those who develop problems following trauma feel different from other people, alone with their distress, or misunderstood by those around them. Often, they doubt whether it is even possible that others can understand what they are experiencing. Trauma survivor support groups, being typically comprised of those who have undergone similar traumatic experiences, are well suited to challenging such perceptions. They may be especially useful in helping survivors address traumas that are difficult to talk about with family and friends (eg, sexual assault), due to perceived social stigma, embarrassment, shame, guilt, or fear of negative reactions from others.3

Some individuals with PTSD become socially isolated, in part because isolation often enables avoidance of trauma reminders and feelings of vulnerability. One effect of this isolation is to cut survivors off from others who might otherwise be of help to them, practically and emotionally. Isolation may enable avoidance of talking about the experience, but this may delay the potentially helpful processing of experience that survivors often require. Support groups provide a useful means to begin reducing social isolation, create an opportunity for contact with others in a safe and structured context, and give help in facing the many ongoing symptoms, stressors, and problems related to the traumatic experience.

 

Group Education

Education is a component of all treatments for PTSD and may be usefully delivered in a group format. PTSD education is intended to improve understanding and recognition of symptoms, reduce fear and shame about symptoms, and, generally, “normalize” the experience of the survivor. Understanding how PTSD develops can make symptoms seem more predictable and less frightening. Recognizing symptom triggers can help individuals cope more effectively with them. Education should also aim to reduce negative forms of coping with symptoms, such as extreme avoidance or alcohol and drug use. In some settings, education should give participants information to help them better decide whether and when to seek further treatment. When PTSD-related education is provided to individuals as part of their formal PTSD treatment, it is important to give them a clear understanding of how recovery is thought to take place, what will happen in treatment, and, as appropriate, the role of medication.

Education includes didactic presentation of materials, but must be accompanied with active prompting of questions and discussion. Simple educational instruction is limited in its impact on more complex actions important to recovery. Whenever possible, presentation of information should be expanded to include opportunity to observe and practice coping behaviors to increase likelihood of behavior change.

 

Trauma-Related Coping Skills Training in Groups

Individuals diagnosed with PTSD have difficulty coping with everyday circumstances and problems.4 Patients often report feeling overwhelmed and are steeped in negative emotions such as shame, guilt, anxiety, and depression.5 PTSD symptoms interfere with healthy coping, interpersonal relationships, and role functioning. One main goal of PTSD treatment is to empower the patient to manage personal difficulties, and training in coping skills can foster its achievement.6

Whereas education groups focus on helping survivors understand their experience and know what to do about it, coping skills training focuses on teaching them know how to do the supportive recovery techniques. It relies on a cycle of instruction that includes education, demonstration, rehearsal with feedback and coaching, and repeated practice. Groups include regular between-session task assignments with diary self-monitoring and the real-world practice of skills. Coping skills can include a range of interpersonal and intrapersonal self-management strategies, such as problem-solving, management of distressing trauma-related thoughts, identification and management of personal trauma “triggers,” relaxation and breathing, anger management, assertion, emotional “grounding,” and use of social support. Skills are selected to target adaptive behaviors that may be new for the individual or may be impaired due to PTSD.

Group therapy is a particularly effective way to train patients diagnosed with PTSD in the use of coping skills. Many of their difficulties are associated with maladaptive patterns in relationships that can interfere with coping. Teaching coping skills in the group setting allows individuals to obtain direct feedback from others about their use of skills and their general interpersonal style. Coping skills training has a here-and-now focus and provides useful tools for change in the immediate environment. Active engagement in new coping behaviors that address current problems faced by patients can serve to lessen distress relatively quickly and help the patient to prepare for more intense therapy if needed.

 

Therapeutic Exposure and Cognitive Restructuring in Groups

The group methods outlined above have not included a detailed in-session exploration of traumatic experiences by participants, nor have they included a detailed review and rethinking of distressing trauma-related beliefs or concerns. However, exposure and cognitive restructuring methods are among the best-validated components of PTSD treatment.2,7 While most of the empirical evidence supporting exposure and cognitive therapy has been derived from examinations of individually-administered care, these treatments can be delivered in groups.

Therapeutic exposure groups include the repeated exploration of traumatic memories as the central treatment component. From a cognitive-behavioral perspective, repeated exposure to distressing aspects of traumatic memories can help reduce the fear and arousal associated with the trauma, and can also help correct faulty perceptions of danger, improve perceived self-control of memories and accompanying negative emotions, and strengthen adaptive coping responses under conditions of distress.6 In “imaginal” exposure, participants verbally recount the details of their experience. This is the primary vehicle for exposure, although it is often supplemented by real-world in vivo exposure to (objectively safe) situations associated with the trauma.

When this therapy is provided in groups, exposure itself is embedded in a range of other group processes and activities. Initial introductory sessions are intended to provide education about PTSD and the treatment process, teach and reinforce basic coping skills, and prepare members for their upcoming task of therapeutic re-experiencing of their traumatic memories. Preparation for exposure is accomplished by setting clear group rules and structure, building group cohesion, discussing realistic expectations for outcome, presenting a clear rationale for exposure treatment, and teaching and supporting coping skills to be consciously employed during and following exposure. After the introductory sessions, trauma scenes are selected and systematic exposure of each member to key individual trauma memories takes place. Finally, relapse prevention and termination sessions focus on helping members consolidate their experiences during exposure, plan for anticipated difficulties, and maintain coping skills.

Compared with individual treatment, the group setting limits the number of traumatic experiences to which an individual may be exposed. Therefore, therapists and group members discuss which traumatic experiences will be explored. Members are encouraged to select scenes that are especially distressing, related to current symptomatology (eg, nightmares), and associated with fear as the predominant affect.

In the group environment, exposure is conducted by focusing upon one member at a time to ensure a minimum of 30 minutes of exposure to important trauma-related reminders, and to prevent cognitive avoidance. In describing their experiences, members are instructed to emphasize their sensory perceptions, thoughts, and emotional reactions that occurred during the event. During recounting of the traumatic experience, the facilitators give minimal directions unless emotional avoidance is occurring; if avoidance is apparent, leaders can ask questions to direct the attention of the survivor to the avoided material. This in-session exposure is supplemented with self-exposure homework. The purpose of the exposure homework is to increase the number of times trauma scenes are re-experienced to ensure that fears are effectively reduced. Typically, cassette recordings of the individual trauma narratives are made, and members are asked to listen to their personal recordings at least once each week, noting distress levels and reporting on coping skills used to manage resultant distress. The goal of the process is to access painful memories but to prevent overwhelming negative emotion.

In order to be considered suitable candidates for this kind of group activity, prospective members should show understanding and acceptance of the rationale for trauma exposure work, willingness to disclose personal traumatic experiences, and ability to establish interpersonal trust with other group members and leaders. Prior group experience and completion of a preparatory course of individual therapy including coping skills training, are very desirable. It is recommended that practitioners not deliver group-administered exposure therapy unless they have received training in the method.

Group treatment can also be used as a vehicle for conducting cognitive restructuring of negative trauma-related beliefs. A range of negative thoughts troubles many trauma survivors, including thoughts of guilt and self-blame, negative views about self (eg, personal weakness) or performance in the traumatic situation, inaccurate concerns about symptoms, problematic views of other people and the world in general, and fears about the future. Group cognitive therapy focuses on educating participants about the relationships between thoughts and emotions, exploring common negative thoughts held by trauma survivors, identifying personal negative beliefs, developing alternative interpretations or judgments, and practicing new thinking. This is a systematic approach that goes well beyond simple discussion of beliefs to include individual assessment, self-monitoring of thoughts, homework assignments, and real-world practice. This kind of cognitive therapy in groups may be less emotionally provocative for participants than exposure therapy, but it may provide significant help to group members.

For more information on this approach, Resick and Schnicke8 incorporate extensive cognitive restructuring and limited exposure therapy in their manual on cognitive-processing therapy. In addition, Young and colleagues9 present a different group-administered combination of exposure and cognitive treatments in the context of disaster-related PTSD.

 

Manualized Group Treatments for Posttraumatic Stress Disorder and Related Problems

There are few manualized interventions that are specific to the treatment of trauma. There are several manuals that have received scientific support or are under investigation and that can guide the practitioner in effective and practical intervention.

Seeking Safety. Developed by Najavits,5 this manualized group treatment for co-occurring PTSD and substance abuse focuses on trauma-related coping skills training. It is designed to help patients gain control over extreme symptoms, reduce risky behavior, reduce trauma-related distress, and reduce substance use. The manual addresses a wide range of interpersonal, behavioral, and cognitive coping skills that can be used with most trauma survivors (not just those with substance abuse problems).

Acceptance and Commitment Therapy. This manualized treatment that has been shown to be effective with sexual abuse trauma survivors10 and is currently under investigation for use with survivors of war trauma.11 The intervention encourages acceptance of avoided internal experience and commitment to valued action in the service of enhancing life experience. Mindfulness exercises and experiential strategies are used to help the patient take action in the face of difficult emotional and
cognitive reactions.

Cognitive-Processing Therapy. This approach has been manualized for use with rape victims.8 However, the methods outlined can be easily adapted for other PTSD populations.

 

Matching Practitioners, Patients, and Group Methods

In deciding whether group therapy and what kind of group methods should be offered to trauma survivors, it is necessary that all potential participants be assessed prior to group participation. Practitioners must use clinical judgment in making these determinations because empirically-based criteria for matching individual patients to either group or individual forms of trauma treatment, or to varieties of group intervention, do not presently exist. Rationally-derived indications and contraindications for group therapy have been put forward, and key considerations include ability to establish trust with others and similarity in terms of traumatic experiences to other group members.1 Contraindications include limited cognitive capacity, active psychosis, and active suicidality or homicidality.

One consideration is how recently the survivor has experienced trauma. Group interventions during the acute phase of trauma response are often delivered to survivors of disaster or other events affecting multiple persons. In addition to supporting individual trauma survivors, they may assist with group cohesion and morale in groups whose members have enduring relationships (eg, firefighters, military units). One of the most common group interventions is “psychological debriefing,”12 the term for a family of interventions that involve bringing survivors together soon after a traumatic event to review the facts of what happened, explore thoughts and feelings associated with the event, and provide education. Overall, evidence for the utility of group debriefing is mixed, and methodologically rigorous studies have yet to be conducted. There has been some concern in the field that a single exploration of traumatic experience in a group or individual setting may exacerbate rather than reduce distress in some survivors. ISTSS practice guidelines recommend that the method should be conducted by experienced, well-trained practitioners, should not be mandatory, and should utilize some clinical assessment of potential participants.13 Studies of other group approaches to early intervention14 have yet to be conducted. Certainly, group support, education, and coping skills training constitute reasonable services to offer recent trauma survivors who want them, although their capacity to prevent development of PTSD has not been demonstrated.

In work with those whose trauma exposure occurred in the more distant past, a basic consideration is the degree to which the patient is likely to be able to tolerate the “opening up” of trauma-related emotions. If the patient does not wish to explore traumatic experiences in detail or is in some other way a poor candidate for trauma-focused therapies, or if the practitioner is not trained in managing the detailed exploration of traumatic experiences, potentially helpful treatment elements—education of participants about stress reactions, “normalization” of reactions to trauma, and instruction in coping—can still be delivered in groups.

Group-administered PTSD education and social support groups may be usefully delivered to most trauma survivors and can often be provided by practitioners who are not specialists in PTSD. However, even in such less emotionally provocative group formats, experience in assessing and treating trauma survivors is necessary in preparing the practitioner to respond to emergent issues. Similarly, clinicians who are familiar with coping skills training with other treatment populations can deliver skills-training groups, but basic clinical familiarity with PTSD is necessary.

 

Group Process Considerations

Evidenced-based reports describing the effectiveness of specific procedural considerations related to the delivery of group treatment for PTSD are lacking. Our clinical experience and the writings of others15-17 suggest some general guidelines. First, there are clear advantages to having two therapists conduct a treatment group for PTSD. While one therapist is presenting material or working more directly with a member, the other therapist can observe the group process and bring others into the discussion.15 This is particularly important in trauma-focused treatment where the account of one group member may trigger an emotional reaction in another. In addition, while group participants are often advised to not leave the group while it is in session, there is often no reasonable way to prevent a member from leaving. A second therapist can either accompany the member who is making his or her way toward the door or consult with the member outside the group room. Having two therapists also allows for postsession (and postgroup) discussions about what took place during the session, what seemed to be effective, what did not work, and what could be done differently the next time. There is the added potential that two therapists bring more clinical skills, experience, and knowledge to the group.

Second, concrete steps should be taken to establish and maintain group identity, cohesion, and trust. Group identity can be fostered by encouraging members to view themselves as survivors who have made a commitment to regaining control of their lives, helping members choose a name for the group, and eventually, if appropriate, encouraging supportive relationships to develop outside the group. Group cohesion and trust are essential to detailed discussions of traumatic experiences and can be achieved through a variety of introductory activities,17 group structures and rules,9 and efforts to maintain active involvement of all group members.

Therapists will need to actively manage relationships between members. When group trauma work addresses existential issues such as dying, exposure to death and horror, social responsibility, fear, and helplessness, group members may at some point “transfer” feelings of hostility toward one another or the group leaders. Group leaders can normalize such reactions and help members explore and understand them. Therapists may themselves also have strong emotional reactions to the issues encountered in trauma groups. It is important that these be anticipated and that group leaders engage in self-monitoring of their responses, take ongoing active coping steps, and seek formal collegial or supervisory support if they find themselves experiencing strong or surprising reactions to the group or its members.

A related responsibility for leaders is to manage difficult group members and those experiencing intense affective reactions. While the need to manage difficult patients is common across treatments and strategies for working with problem patients have been described in the general group literature,18 individuals in treatment for PTSD often have a high levels of irritability, alienation, mistrust, or difficulty in managing anger. When a group member becomes angry or enraged during a session, it is recommended that the leaders quickly intervene to demonstrate that the group remains under their control (thus upholding safety), while validating the survivor’s anger, and giving clear messages about what is permissible in the group (referring to previously established ground-rules).

Finally, it is important in any session to keep an active involvement of all group members. There may be a primary speaker, but routinely encouraging others to speak as well is recommended. When a participant is providing “too much” detail, is tangential, or is monopolizing group time, we recommend that the group leader(s) validate the survivor’s need to talk, while emphasizing the importance of hearing from other members during the limited group time. Depending on the spoken content, a group leader can ask the survivor to “hold that thought” while giving a commitment to later give the survivor more time. When returning, the therapist might say “Tom, you were thoughtful enough to give the floor to Allen. We have a few minutes left and I wanted to get back to you. Can you find a way to briefly tell us what you felt you needed to say, or should we talk after group, or do you want to wait till the next session to share with the group?”

 

Conclusion

Group treatments for PTSD may offer much of value to the trauma survivor, from emotional and practical support, to education about trauma and its impact, to training in more effective ways of coping. Groups can also be used to deliver therapeutic exposure and cognitive therapy, two of the best-validated forms of PTSD treatment. Selection of group approach must depend on time since traumatization, patient functioning and motivation, targets of treatment, and the experience and skills of the practitioner. Group services for trauma survivors are certain to remain a staple of clinical care. The effectiveness is suggested by clinical experience but requires empirical demonstration.  PP

 

References

1. Foy DW, Glynn SM, Schnurr PP, et al. Group therapy. In: Foa EB, Keane TM, Friedman MJ, eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: Guilford; 2000:155-175.

2. Foa EB, Keane TM, Friedman MJ. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York, NY: Guilford; 2000.

3. Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford; 1993.

4. Herman JL. Trauma and Recovery. New York, NY: Basic Books; 1992.

5. Najavits LM. Seeking Safety: A Treatment manual for PTSD and Substance Abuse. New York, NY: Guilford; 2002.

6. Foy DW, Ruzek JI, Glynn SM, Riney SJ, Gusman FD. Trauma focus group therapy for combat-related PTSD. An update. J Clin Psychology. 2002;58:907-918.

7. Foa EB. Psychological processes related to recovery from a trauma and an effective treatment for PTSD. Ann N Y Acad Sci. 1997;821:410-424.

8. Resick PS, Schnicke MK. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, Calif.: Sage; 1993.

9. Young BH, Ruzek JI, Ford JD. Cognitive-behavioral group treatment for disaster-related PTSD. In: Young BH, Blake DD, eds. Group Treatments for Post-Traumatic Stress Disorder. Philadelphia, Penn: Taylor & Francis; 1999:149-200.

10. Follette VM. Acceptance and commitment therapy in the treatment of incest survivors: a contextual approach. In: Hayes SC, Jacobson NS, Follette VM, Dougher M, eds. Acceptance and Change: Content and Context in Psychotherapy. Reno, NV: Context Press; 1994.

11. Walser RW, Gregg JA, Westrup D, Rogers D, Loew D. Acceptance and commitment therapy: treatment of complex PTSD. Paper presented at: Annual Meeting of the International Society for Traumatic Stress; November, 2002; Baltimore, MD.

12. Mitchell JT. When disaster strikes. J Emerg Med Serv. 1983;8:36-39.

13. Bisson JI, McFarlane AC, Rose S. Psychological debriefing. In: Foa E, Keane T, Friedman M, eds. Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York, NY: Guilford; 2000:39-59.

14. Ruzek JI. Providing “brief education and support” for emergency response workers: An alternative to debriefing. Mil Med. 2002;167(suppl 9):73-75.

15. Chard KM, Resick PA, Weertz JJ. Group treatment of sexual assault survivors. In: Young BH, Blake DD, eds. Group Treatments for Post-Traumatic Stress Disorder. Philadelphia, Penn: Taylor & Francis; 1999:35-50.

16. Harney PA, Harvey MR. Group psychotherapy: An overview. In: Young BH, Blake DD, eds. Group Treatments for Post-Traumatic Stress Disorder. Philadelphia, Penn: Taylor & Francis; 1999:1-14.

17. Zaidi LY. Group treatment for adult survivors of childhood sexual abuse. In: Young BH, Blake DD, eds. Group Treatments for Post-Traumatic Stress Disorder. Philadelphia, Penn: Taylor & Francis; 1999:201-220.

18. Yalom ID. Theory and Practice of Group Psychotherapy. 4th ed. New York, NY: Basic Books; 1995.

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Laurence M. Westreich, MD

Primary Psychiatry. 2008;10(7):65-72

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Charles DeBattista, MD, and Alan F. Schatzberg, MD

Primary Psychiatry. 2003;10(7):80-96

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Jonathan M. Metzl, MD, PhD, and Michelle Riba, MD

Primary Psychiatry. 2008;10(7):45-48

 

Dr. Chemali is director of the Neuropsychiatry Brigham Behavioral Neurology Group Memory Disorders Unit at Brigham and Women’s Hospital, Harvard Medical School, in Boston, Massachusetts.

Disclosure: The author reports no financial, academic, or other support for this work.

Please direct all correspondence to: Zeina Chemali, MD, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Boston, MA 02115; Tel: 617-732-8060; Fax: 617-738-9122; E-mail: zelchemali@partners.org


 

Focus Points

This report of two case studies in elderly women represents the first published incidence of increased libido and hypersexuality associated with donepezil.

Physicians should be aware of the possibility of this side effect, which was distressing to the elderly patients in the presented cases.

A possible neurochemical mechanism of action of cholinesterase inhibitors leading to increased sexual arousal is presented.

Abstract

Can donepezil affect the sexual response in the elderly population? Donezepil, an acetylcholine inhibitor, is commonly used in neuropsychiatry for the treatment of cognitive decline and dementia. This report addresses two elderly female patients who had an increase in their libido and experienced hypersexuality after starting donepezil treatment. Potential explanations for this previously unreported association are discussed.

 

Introduction

Donepezil (Aricept) is a centrally active, selective piperidine acetylcholinesterase (AchE) inhibitor with no effect on butyrylcholinesterase (BuChE). Its action on AchE inhibition is reversible.1 The drug is given orally in the dose of 5–10 mg OD. Donepezil exhibits linear pharmacokinetics and reaches its peak plasma level within 3–4 hours after ingestion of the drug. It is metabolized in the liver via cytochrome P450 (CYP) and is preferentially excreted by the kidneys. The half-life of donepezil is 60 hours but can extend up to 100 hours in elderly subjects.

Donepezil is relatively well tolerated. Predominant adverse effects are nausea, vomiting, diarrhea, muscle cramps, insomnia, fatigue, and anorexia. Neurological side effects include dizziness, vertigo, ataxia, restlessness, paresthesia, tremor, seizures, drowsiness, extrapyramidal symptoms, and abnormal crying.2 The causes of these signs are unclear, although they are usually attributed to the drug’s direct cholinergic effects. A few cases of behavioral changes have been reported with donepezil.3-5 They include, but are not limited to, delirium, delusions, irritability, aggression, nervousness, paranoia, and abnormal dreams.

There is no report on the effect of donepezil on sexuality. This report describes two cases of increased libido and hypersexuality experienced by female patients 10 days after starting donepezil treatment targeting their cognitive symptoms.

 

Case 1: Mrs. N

Mrs. N, an 81-year-old right-handed woman, complained of cognitive changes that had been occurring over the last 3 years. Symptoms involved forgetfulness of names and dates of events, as well as word-finding difficulties. These symptoms later progressed to difficulty following conversations and balancing her checkbook. She also had a history of depression and anxiety treated with fluoxetine. She stopped taking fluoxetine a few months later, as she believed it exacerbated her cognitive symptoms. Later, she was placed on a lower dose of the drug without much success. It was then stopped. Her work-up lead to the diagnosis of mild mixed dementia. She was placed on donepezil 5 mg QOD, which was later increased to 5 mg/day. Her other medications included warfarin sodium crystalline, diltiazem, alendronate sodium, levothyroxine, simvastatin, and a multivitamin.

She noticed an increase in her sexual libido 1 week after beginning the regular dose of donepezil 5 mg/day. She described the feeling as overwhelming. She described obsessive sexual thoughts and the urge to have sex many times during the day. She felt very embarrassed and asked to stop donepezil. An attempt to decrease the donepezil dose to alleviate the symptoms while continuing the medication, was unsuccessful. She stopped taking donepezil and her symptoms abated a few days later. At 6-month follow-up, she noted that she had no recurrence of these symptoms since she stopped taking the drug.

 

Case 2: Mrs. M

Mrs. M is a 72-year-old right handed woman who had once had a motor vehicle accident. Subsequent to her accident, she had complained of short-term memory loss and word-finding difficulties. She was diagnosed with mild cognitive impairment of the amnestic type. In addition, she suffered from depression and was on citalopram 20 mg/day when she started donepezil 5 mg QOD which was increased to 5 mg/day. Mrs. M became restless, had pressured speech, and complained of increased libido and obsessive sexual thoughts 1 week after she started donepezil. A hypomanic state was diagnosed and her citalopram was tapered off and stopped. Her agitation and pressured speech abated but she continued to complain of the same sexual distressing thoughts leading to frequent masturbation. These thoughts and actions were intolerable to her. She stopped taking donepezil. The symptoms of sexual hyperactivation, increased libido, and compulsive masturbation abated a few days later. At a 3-month follow-up she was found to be moderately depressed, but no other complaints were made. She was treated with bupropion. A year later, the depression was in remission with no recurrence of the unwanted sexual behaviors.

 

Discussion

Donepezil is considered to be an essential drug in the treatment of dementia. Its action is due to acetylcholinesterase inhibition and the increase of acetylcholine available to neurons. Donepezil’s affect on sexuality has not been described. One may advance that it is due to the direct cholinergic effect on sexual end organ as the parasympathetic postganglionic neurons and their neurotransmitter acetylcholine are stimulatory to the genitourinary system. This stimulation leads to bladder contraction and increases sexual arousal causing vasodilatation of blood vessels and an increase in blood flow to the sexual organs.

In addition, acetylcholine as a central neurotransmitter is involved in sexual arousal along with nitrous oxide. This type of arousal follows the stage of libido activation and prepares the genitalia for penetration and intercourse. The message of arousal starts in the brain and is relayed in the spinal cord to sympathetic and parasympathetic nerve fibers, vascular tissue, and genitalia.

Previous reports by Kawashima and Yamada3 noted delirium and increased diurnal and nocturnal activation after the use of donepezil. In addition, Wengel and colleagues4 described behavioral complications associated with donepezil, while another report described violent behavior associated with donepezil.5

It is worth noting that both women presented in these cases had a history of depression and were treated with selective serotonin reuptake inhibitors (SSRIs). In case 2, competition for CYP with the addition of donepezil may have triggered a hypomanic state with hypersexuality, gregariousness, and disinhibition by raising SSRI levels. While the rest of the hypomanic symptoms abated when the patient stopped the SSRI, the hypersexuality did not abate until she stopped donepezil.

The two women were very disturbed by their behaviors and found it to be distressing and unacceptable. Decreasing the dose did not make any difference and the behavior abated only when the medication was completely stopped. No subsequent sexual problems were noted at follow-up visits.

 

Conclusion

Two cases of donepezil treatment associated with side effects of increase libido and hypersexuality were presented. Because of the high frequency use of donepezil and the special elderly population it targets, physicians should be cognizant of this possible side effect along with or in the absence of major mental status changes. In addition, when donepezil is added to other agents, pharmacokinetics and drug interaction must be considered. Further research in this area is needed.  PP

 

References

1. Stahl S. Essential Psychopharmacology. Neuroscientific Basis and Practical Applications. 2nd ed. New York, NY: Cambridge University Press: 2000:479-489.

2. Physicians Desk Reference. Montvale, NJ: Medical Economics Company, Inc.; 2002:2469-2473.

3. Kawashima T, Yamada S. Delirium caused by donepezil. J Clin Psychiatry. 2002;63:250-251.

4. Wengel SP, Roccaforte WH, Burke WJ, Bayer BL, McNeilly DP, Knop D. Behavioral complications associated with donepezil. Am J Psychiatry. 1998;155:1632-1633.

5. Bouman WP, Pinner G. Violent behavior associated with donepezil. Am J Psychiatry. 1998;155:1626-1627.

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Kathryn J. Zerbe, MD

Primary Psychiatry. 2003;10(6):76-78

 

Dr. Michel is clinical assistant professor in the Department of Psychiatry and Neurology at the Tulane University School of Medicine in New Orleans, Louisianna.

Dr. Willard is professor in the Departments of Psychiatry, and Neurology and Pediatrics at the Tulane University School of Medicine.

Disclosure: The authors report no financial, academic, or other support of this work.

Please direct all correspondence to: Deborah M. Michel, PhD, 824 Amethyst St, New Orleans, LA 70124; Tel: 504-282-7191; Fax: 504-282-7196; E-mail: dmarcon@tulane.edu


 

Focus Points

The role that family dynamics can potentially play in the development and maintenance of eating disorders is delineated.

Areas of inquiry for the assessment of family dynamics are presented.

The importance of family therapy in multidisciplinary treatment of eating disorders is discussed and a brief literature review of support for family treatment of eating disorders is provided.

Common issues that arise during the course of family treatment of eating disorders are outlined.

 

Abstract

How is family treatment of eating disorders conducted and when is it warranted? This article briefly reviews the important role family dynamics can play in the development and maintenance of eating disorders and summarizes support for family treatment of eating disorders. The review presents areas for inquiry in the assessment of family dynamics and discusses the role of family therapy in multidisciplinary treatment. Common issues that arise in the course of therapy are also delineated.

 

Introduction

The family dynamics of those with eating disorders, particularly anorexia, have been of interest to clinicians since the disorders were first described1,2 and well past the time that they were recognized as psychological problems.3 In particular, practitioners have noted the association between eating disorders and difficulty with individuation and separation from the family of origin. Peer relationships are vitally important during the developmental stage that occurs between childhood, during which family is the main source of support, and adulthood, when nonfamilial resources become paramount. During adolescence, it is imperative for friends to become of primary interest and for the family to recede to secondary status. If this phenomenon does not occur, the adolescent’s development of normal peer relationships may be inhibited, thus depriving the youngster of appropriate “growing up” experiences. Without a peer group, it is next to impossible to make the necessary transition from the family to the larger world.

The notion that dysfunctional family characteristics play a part in the development of eating disorders is controversial, as some clinicians believe that the observed family problems are a result rather than the cause of the stress associated with having a child with such a frightening illness.4 There is mounting evidence that genetics contribute to the development of eating disorders, although it is commonly believed that an interaction occurs between genetics and environmental stressors that spawns these disorders.5 What we do know is that the family represents the holding environment for the child and it is always necessary to look at which aspects of the family might relate to the occurrence and maintenance of the disease while remembering that it is never useful or appropriate to blame family members for the disease.3

The ways in which family dynamics may contribute to the development of an eating disorder vary. For example, the family may provide an atmosphere which hinders a youngster from establishing an identity, practicing effective communication skills, and/or learning adaptive coping strategies. Furthermore, within the context of the family, an eating disorder may help an adolescent establish a distinct and separate identity from the family, cope with stressors, distract from negative feelings, or provide what she or he considers to be a means of “safe” self expression in an environment that does not allow open self expression.3

We have noted6 that there have been many clinical accounts of the effectiveness of family therapy in the treatment of eating disorders, yet relatively few controlled studies. However, these few studies clearly show that family therapy is an effective modality for treating eating disorders, particularly in adolescents with anorexia. Investigations with families of bulimics also support the use of family treatment, although fewer studies have been conducted with this population compared to families of anorexics. Taken together, research and clinical experience has convinced us that family therapy is a critical part of treatment within a multidisciplinary team approach, and the need for family therapy from a biopsychosocial stance is now widely accepted.4 A more critical overview of the literature in this area is available in Eating Disorders.6

 

Assessment of Family Dynamics

The family therapy process begins with an assessment and is a continuous process throughout treatment.6,7 The assessment involves an evaluation of individual family members as well as the family unit as an interrelated system. Thus, the evaluation will necessarily include all family members living within the home. Other extended family members may also be asked to take part in the assessment if they have a significant relationship with the identified patient. The goal of the assessment is to determine if the familial environment played a role in the development and maintenance of the eating disorder and, if so, to identify the extent to which any problematic issues remain.8 The assessment also addresses how the eating disorder functions within the family system. During the evaluation, it is important to identify: (A) how the symptoms stabilize the family; (B) what role the family plays in stabilizing the symptoms; (C) around what themes the problem is organized; (D) what consequences will follow familial change; and (E) the therapeutic problem or dilemma.7

When conducting the evaluation, the practitioner should begin by obtaining standard psychosocial information for each family member including demographic data, current and previous living arrangements, psychiatric history, medical history, educational and occupational history, social history, and trauma history.6 It is also important to inquire about significant family events as well as family traditions. Gathering background information on each parent’s family of origin will promote identification of multigenerational patterns of relating and behaving.

As recommended by Anderson,9 there is a need to investigate other areas as well.6 First, interactional patterns should be evaluated including marital satisfaction, extent of spousal agreement on parenting, family satisfaction and companionship, patterns of communication, and the overall affective atmosphere of the family. Second, it is important to assess degree of flexibility in allowing family members to alter communication patterns and roles in response to situations and stressors. Third, clinicians should evaluate how sensitive family members are toward one another. Are they hypersensitive and overreactive, uninvolved and insensitive, or somewhere in between? Furthermore, it is suggested that supports and stresses be evaluated. More specifically, degree of support, or lack thereof, that family members afford one another should be assessed in addition to any significant sources of strengths and stressors both within and outside of the family.

Practitioners must also assess the age-appropriateness of rules and responsibilities that are assigned to family members, especially children and adolescents. Lastly, family knowledge of the eating disorder is a critical area of inquiry in terms of etiology, treatment, and recovery in addition to thoughts, feelings, and behaviors associated with it. Family attitudes and behaviors that may impede recovery need to be identified and resolved quickly,8 particularly preoccupations with weight and appearance which may undermine the identified patient’s efforts at recovery.10 Relatedly, it is important to obtain a family history of dieting, exercise, and eating disorders.3

To assist clinicians in family assessment, standardized, self-report measures are available such as the Family Adaptation and Cohesion Evaluation Scale11 and the Family Assessment Measure.12 These instruments examine the quality of familial relationships and familial interactions from an individual family members’ perspective.6 Although these instruments are subject to self-reporting bias, they can nevertheless be helpful secondary sources of information.

 

Treatment: A Multidisciplinary Approach

As we have written previously,6 recognition of the complexity of eating disorders, combined with the realization that no single healthcare professional can provide comprehensive care for these patients, led to the evolution of a multidisciplinary team approach.3 Family therapy is one arm of this approach. It is based on the tenet that the family is a system, or a group of interconnected parts which affect one another in a stable manner.13 Consequently, the psychotherapeutic focus is on the family system as a whole, instead of any individual member.6 We have stated3 that the family is the context out of which an eating disorder typically arises, and accordingly, necessitates change if an adolescent is to overcome the eating disorder in that environment. As a result, family therapy is often geared toward understanding the role that the identified patient has characteristically played within the family system and how he or she has contributed to maintaining whatever homeostasis has been achieved.

Homeostasis refers to the balance that occurs when all family members adhere to their given, often unspoken, rules of behavior. These rules can be quite rigid, thereby preventing family members from learning more adaptive, flexible coping mechanisms in response to life stressors. In some cases, patients do well in treatment without family participation, especially if the family exhibits a high degree of negative expressed emotion.14 Older patients who do not live with their families of origin may not need family therapy unless it is determined that the family continues to be a stimulating factor in the illness. These patients may be in family therapy with their spouses and children. When a patient still lives with her family, however, family therapy is usually recommended. Marital therapy may be suggested as an adjunctive treatment for those with spouses.3

Family therapy may evolve into marital therapy for the parents of the identified patient or individual therapy for one or both parents. In other cases, these psychotherapies may be recommended as adjunctive treatments. Furthermore, it is not unusual for one of the parents to be referred for individual therapy at the outset of treatment if it is clear that the primary family problem lies within that particular parent-child relationship.3

We have reported6 that family therapy conducted in conjunction with individual psychotherapy greatly improves prognosis10 and is recommended in the Practice Guideline for the Treatment of Patients with Eating Disorders.15 For theoretical or practical reasons, some practitioners treat both the identified patient and the family. We prefer a model using separate therapists for individual and family therapy on the following grounds3: (A) facilitation of the individuation-separation process; (B) less complicated management of confidentiality issues; and (C) division of therapeutic responsibilities.16 This model also addresses any family dysfunction on both an individual level, where it has been introjected, as well as on the present family level.17 Finally, there are some schools of family therapy that advocate parental control over the child’s eating and a professional, family-based treatment manual is available outlining one such method.6,18 It has been noted, however, that most clinicians do not follow this approach.19 In our experience, having a registered dietician (nutritional counselor) with expertise in eating disorders handle all food issues has been most beneficial. In this manner, the family and identified patient can relinquish battles surrounding food, strengthen familial relationships, and focus on relevant psychotherapeutic issues.6

At times, families may present obstacles to the assessment and treatment process.20 Potential difficulties include denial of a problem, minimization of the eating disorder, and/or denial of the psychological origins of the illness. Treatment resistance and lack of familial motivation to change may also be present. Family refusal to participate in treatment and/or to cooperate with treatment recommendations can have a devastating effect on the course of the illness and the potential for recovery.3 When family members refuse to take part in recommended treatment, the patient often feels that he/she alone is the one with “the problem” and is in some way defective. The aforementioned challenges must be confronted and resolved early in treatment so that a therapeutic alliance can be established, thereby enhancing the probability of a successful outcome.20

In response to familial disagreement with some aspect of treatment or treatment recommendations, the family therapist, and possibly the entire treatment team if appropriate, should meet with the family to work out those differences.3 Dealing with such problems in this manner models adaptive coping skills for the entire family and creates an atmosphere of mutual cooperation and respect in which healing can take place.

 

Common Issues

Although each case of an eating disorder develops for a variety of individualized reasons, that there are issues commonly encountered in family therapy.3,6 One such issue is difficulty with communication. This problem may be characterized by miscommunication, lack of communication, mixed or double messages, or failure to allow overt expression of feelings, either directly or indirectly. Another typical theme involves problems with the separation-individuation process and difficulties that the family has in allowing the child to become independent. Lack of appropriate parent-child boundaries (eg, failure to respect privacy), enmeshment (emotional overinvolvement), or disengagement (emotional distance), are also frequently seen. As mentioned earlier, the roles that family members play which contribute to the development and maintenance of the eating disorder must also be addressed. For example, a sick child might be the mediator between parents in a strained marriage. In addition, the family often has unrealistic expectations of individual members, such as the “superstar child.” Finally, issues of power and control within the family are likely to surface. For more detailed information on family therapy in the treatment of eating disorders, see the list of suggested readings.

 

Conclusion

Family therapy is an effective modality of treatment for eating disorders, particularly when used in conjunction with individual psychotherapy and nutritional counseling as part of multidisciplinary treatment. For younger patients still living with their families of origin, it is usually essential for recovery and requires the participation of all family members. If the family is highly defensive and critical, parent counseling or family therapy without the identified patient may be recommended. For older patients, family therapy may not be necessary unless the family is thought to play a role in the maintenance of the illness.

A careful and continuous assessment of family dynamics is warranted in order to ascertain the therapeutic needs of the family and to implement appropriate interventions. Family therapy can then be expected to surround common themes while also addressing individualized family concerns. At times, families may present challenges to the assessment and treatment process. These difficulties must be identified, addressed, and resolved early in treatment in order to increase the potential for a successful outcome.  PP

 

References

1. Gull WW. Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society of London. 1874;7:22-28.

2. Lasegue C. De l’anorexie hysterique. Archives Generales de Medecine. 1873;1:384-403. French

3. Michel DM, Willard SG. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, CT: Yale University Press; 2003.

4. Lemmon CR, Josephson, AM. Family therapy for eating disorders. Child Adolesc Psychiatr Clin N Am. 2001;10:519-542.

5. Klump K. A genetic link to anorexia. In: DeAngelis T, ed. Monitor on Psychology. 2002;33:34-36.

6. Michel DM, Willard SG. Family evaluation and therapy in anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton TD, ed. Eating Disorders. New York, NY: Marcel Dekker. In Press.

7. Vanderlinden J, Vandereycken W. Family therapy within the psychiatric hospital: indications, pitfalls, and specific interventions. In: Vandereycken W, Kog E, Vanderlinden J, eds. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York, NY: PMA Publishing; 1989:263-310.

8. Woodside DB, Shekter-Wolfson LF, Garfinkel PE, Olmsted MP. Family interactions in bulimia nervosa II: complex intrafamily comparisons and clinical significance. Int J Eat Disord. 1995;17:117-126.

9. Andersen AE. Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia. Baltimore, MD: The Johns Hopkins University Press; 1985:135-148.

10.Pelch BL. Eating disordered families: issues between the generations. In: Lemberg R, Cohn L, eds. Eating Disorders: A Reference Sourcebook. Phoenix, AZ: Oryx Press; 1999:121-123.

11. Moos RH, Moos BS. Family Environment Scale Manual. 2nd ed. Palo Alto, CA: Consulting Psychologists Press; 1986.

12. Waller G, Slade P, Calam R. Family adaptabity and cohesion: relation to eating attitudes and disorders. Int J Eat Disord. 1990;9:225-228.

13. Foley VD. Family therapy. In: Corsini RJ. Current Psychotherapies. 3rd ed. Itasca, IL: FE Peacock Publishers; 1984:447-490.

14. Le Grange D, Eisler I, Dare C, Hodes M. Family criticism and self-starvation: a study of expressed emotion. J Fam Ther. 1992;14:177-192.

15. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders. Am J Psychiatry. 2000;57(suppl 1):1-39.

16. Brandes J. Outpatient family therapy for bulimia nervosa. In: Woodside DB, Shekter-Wolfson L, eds. Family Approaches in Treatment of Eating Disorders. Washington, DC: American Psychiatric Press; 1991:49-66.

17. Gowers S, Norton K, Halek C, Crisp AH. Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa. Int J Eat Disord. 1994;15:165-177.

18. Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York, NY: Guilford Press; 2002.

19. Goldner EM, Birminghan CL. Anorexia nervosa: methods of treatment. In: Alexander-Mott L, Lumsden DB, eds. Understanding Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Obesity. Washington, DC: Taylor & Francis; 1994:135-157.

20. Michel DM. Psychological assessment as a therapeutic intervention in hospitalized patients with eating disorders. Prof Psychol Res Pract. 2002;33:470-477.

Suggested Readings

Dare C, Eisler I. Family therapy for anorexia nervosa. In: Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders. New York, NY: Guilford Press; 1997.

Le Grange D. Family therapy for adolescent anorexia nervosa. J Clin Psychiatry. 1999;55:727-739.

Lock J, Le Grange D, Agras WS, Dare C.
Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York, NY: Guilford Press; 2002.

Michel DM, Willard SG. Family evaluation and therapy in anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton TD, ed.
Eating Disorders. New York, NY: Marcel Dekker. In Press.

Michel DM, Willard SG. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, CT: Yale University Press; 2003.

Minuchin S, Rosman BL, Baker L. Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, MA: Harvard University Press; 1978.

Root MPP, Fallon P, Friedrich WN. Bulimia: A Systems Approach to Treatment. New York, NY: W.W. Norton and Co.; 1986.

Schwartz RC, Barrett MJ, Saba G. Family therapy for bulimia. In: Garner DM, Garfinkel PE, eds.
Handbook of Treatment for Eating Disorders. New York, NY: Guilford Press; 1985.

Selvini-Palazzoli M, Aronson J. Self-Starvation. New York, NY: Jason Aronson; 1974.

Vandereycken W, Kog E, Vanderlinden MA. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York, NY: PMA Publishing; 1989. 

Woodside B, Shekter-Wolfson L, Brandes J, Lackstrom J. Eating Disorders and Marriage. New York, NY: Brunner/Mazel; 1993.

Woodside DB, Shekter-Wolfson L, eds. Family Approaches in Treatment of Eating Disorders. Washington, DC:?American Psychiatric Press; 1991.

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