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18. Is there a place for brief group therapy? Time-limited treatment is becoming more common because of cost-limited care. Time-limited groups often are formed around specific symptoms, crises, or common issues (for example, medical illness, divorce, or adolescence) with limited goals of symptom relief, crisis management, or support and psychoeducation. Brief-treatment groups also are designed for more aggressive interpersonal intervention and more ambitious therapeutic change. They have in common a careful selection of patients, explicit goals, a well-defined working focus, rapid application of learning, active leaders, the use of interpersonal resources, and the use of time limits to accelerate behavior change. Unlike longer-tenn groups, patients can return for several courses of treatment; in both, success is predicated on careful pregroup preparation. Time-limited groups also can be conceptualized as having developmental stages (see Question 14). Progression through stages may be intensified because of the time limit.

19. Can the leader guarantee confidentiality? The legal and ethical responsibility to protect the patients privacy and confidentiality is uncompromised and uncomplicated for the therapist doing individual treatment. However, although the same standard applies for the group therapist, group therapy poses special problems because patients are expected to respect the identities and protect the information shared by other group members. In actuality, group therapy places limits on confidentiality (when one group member violates the confidentiality of another) because neither the leader nor the other group members have any legal means of enforcement.
BIBLIOGRAPHY
1 . Agazarian YM: System-Centered Therapy for Groups. New York, Guilford Press, 1997. 2. Alonso A, Swiller HI (eds): Group Therapy in Clinical Practice. Washington, DC, American Psychiatric Association Press, 1993. 3. Bernard HS, MacKenzie KR (eds): Basics of Group Psychotherapy. New York, Guilford Press, 1994.. 4. Dies RR: Models of group psychotherapy: Sifting through the confusion. Int J Group Psychother 42: 1-17, 1992. 5. Kaplan HI, Sadock BJ (eds): Comprehensive Group Psychotherapy. Baltimore, Williams &Wilkins, 1993. 6. Klein RH, Bernard HS, Singer DL (eds): Handbook of Contemporary Group Psychotherapy: Contributions From Object Relations, Self-Psychology, and Social Systems Theories. Madison, CT, International Universities Press, 1992. 7. Roth BE, Stone WN, Kibel HD (eds): The Difficult Patient in Group. Madison, CT, International Universities Press, 1990. 8. Rutan JS, Stone WN: Psychodynamic Group Psychotherapy. New York, Guilford Press, 1993. 9. Scheidlinger S: Group dynamics and group psychotherapy revisited: Four decades later. Int J Group Psychother 47:141-159, 1997. 10. Steenbarger BN, Budman SH: Group psychotherapy and managed behavioral health care: Current trends and future challenges. Int J Group Psychother 46:297-309, 1996. 11. Yalom ID: The Theory and Practice of Group Psychotherapy. New York, Basic Books, 1995.

46. RELAXATION TRAINING

1. What are the major forms of relaxation training? Self-guided, passive attention to single object of focus Meditation Progressive muscle relaxation Systematic contraction and relaxation of major muscle groups Hypnosis Verbal and repetitive suggestions, often involving mental imagery, to relax mind and body Autogenic training Structured series of formalized suggestions directed toward promoting body sensations associated with relaxation

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Biofeedback
Machine-based detection and amplification of tensionrelated physiological signals; signals are fed back to patient, who learns to sense and modify signal

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2. Describe meditation.
Abbreviated (i.e., nonreligious) versions of meditational systems, usually of the concentrative form, have become increasingly popular in the West. In concentrative meditation, the patient is taught to attend passively to a single object of focus that is unchanging or repetitive (e.g., a visual image, a repeated word or mantra, or a body sensation such as breathing). The emphasis is on present-centered, effortless attention, often without any directive guidance that relaxation or any other psychophysiological change should occur. Nonconcentrutive forms are similar, though usually more difficult, with the attention directed in a more expansive or mindful manner towards the everchanging flow of mental activity.

3. Describe progressive muscle relaxation.

The patient is guided in the tensing and relaxing of 16 major muscle groups, one group at a time. Of the major relaxation forms, progressive muscle relaxation may be the most simple, straightforward, and teachable. Voluntary muscle contraction allows the patient to sense the difference between tension and relaxation in each of the muscle groups and enables subsequent muscle relaxation. Recent research, however, suggests that the tensing component may not be necessary; abbreviated techniques involving awareness of each muscle group followed by suggestions for relaxation may be just as effective. As the progressive muscle relaxation skill is developed, patients are encouraged to combine muscle groups, until relaxation is achievable through simple recall.

4. How is hypnosis relaxing? Hypnosis and self-hypnosis both focus on formalized suggestion, often involving mental imagery. Hypnotic suggestion may be applied toward a variety of different ends, of which the most well known is relaxation. With a rhythmic and calming voice, repetitive suggestions are used to guide the patient toward somatic relaxation (e.g., the muscles of your body are relaxing more and more) and cognitive relaxation (e.g., slowly let go of the days worries). Of all the hypnotic suggestions, relaxation is one of the easiest to attain, though there is considerable evidence that individuals differ greatly in their ability to respond to hypnotic suggestion.

5. Is autogenic training a form of hypnosis?

Yes. It involves a series of six self-suggestions referring to specific body sensations. In the course of treatment, patients are slowly guided in the promotion of each group of sensations (e.g.. the heart is beating quietly and strongly, the forehead is cool) in a step-by-step manner, which is believed to promote relaxation. Strong emphasis on passive concentration encourages the patient to allow, rather than force, changes in body sensations. As in progressive muscle relaxation, after autogenic skills are acquired, abbreviated forms are introduced so that the patient can more reliably and rapidly achieve states of deep relaxation.

6. In biofeedback, its hard to see the benefit of relying on a machine for relaxation. The biofeedback system simply relays information, via visual and/or auditory signals, back to the patient. The patient then learns to modify the signals, thereby modifying the associated physiological system in the desired direction. Biofeedback interventions can promote states of deep relaxation through directed reductions in, for example, electrodermal activity, heart rate, and muscle tension. Ideally, the patient is slowly weaned from the biofeedback system.

7. Does biofeedback have other uses? Biofeedback is a multidimensional tool in that it can be used to promote a number of potentially valuable physiological changes that are not necessarily associated with relaxation. For example, electromyographic biofeedback training is used in neuromuscular rehabilitation to assist patients in

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re-learning to perceive, activate, and/or relax specific muscles, followed by the regaining of patterned muscle movement. The complexity and specificity of such training is clearly distinct from relaxation training (RT). Biofeedback training has been proven useful in a variety of other syndromes, including Raynauds disease and encopresis.

8. What is the relaxation response?

Benson suggested that all types of RT are remarkably similar. Almost all types involve verbal repetition and a passive attitude toward external stimuli, and all lead to the same, generic result-the relaxation response. This response is characterized by muscle relaxation, diminished heart rate, reduced blood pressure, and other psychopathological changes indicative of a broad reduction in sympathetic arousal.

9. True or false: All types of relaxation training produce the same result.
True and false. This is a point of considerable controversy. In contrast with the relaxation response model, some researchers argue for a specific effects model, suggesting that somatic and cognitive forms of relaxation may be more effective when matched with the appropriate form of anxiety (e.g., complaints of chronic muscle tension versus racing thoughts). The evidence to date suggests that a compromise is warranted: each form of RT has been shown to promote general, stress-reducing effects as well as specific effects. For example, progressive muscle relaxation and biofeedback (somatic) have more powerful effects than meditation (cognitive) on body-oriented anxiety, such as a rapid heart rate. Meditation appears to impact more strongly when the anxiety is primarily psychological, such as excessive worrying. (For a more comprehensive discussion, see Lehrer, et al., 1994.)

10. Which psychiatric problems have been helped by relaxation training? Generalized anxiety disorder, social phobia, depression, chronic substance abuse, and other disorders in which anxiety is a central factor. While RT is widely viewed as an effective panacea, as a solitary intervention it is unlikely to be sufficient for most conditions. Powerful and effective stress management treatment packages have been developed, especially for anxiety-related diagnoses. For example, cognitive intervention and therapist-directed exposure have been remarkably effective in promoting long-term symptom reduction in agoraphobia and panic disorder (Craske and Barlow, 1993). RT usually is part of a comprehensive treatment program, and as such it generally adds to treatment efficacy (especially when focused on breathing retraining-slow, paced diaphragmatic breathing), but it is clearly a second-tier treatment. Cognitive therapy interventions usually are central, and relaxation techniques are directed towards situation-specific practice (e.g., learning to relax before and during difficult social situations.) 11. How are stress management programs different from relaxation training? Stress management programs commonly involve a broad range of techniques, usually including RT, directed towards the amelioration of stress-mediated conditions. In contrast to RT, these programs tend to be multifaceted. One well-known program is anxiety management training (Suinn, 1990), which packages a number of cognitive therapy techniques along with progressive muscle relaxation. The goal is applied relaxation, and patients are trained to: repeatedly imagine anxiety-provoking scenes and use their relaxation skills to reduce the anxiety: recognize and treat the early signs of stress: and practice their relaxation skills during anxious moments. Other programs are more directly focused on specific psychiatric conditions. For example, Barlow and colleagues have developed a program for panic disorder that features relaxation techniques, cognitive restructuring (to identify the common cognitive errors that contribute to panic), and graded exposure to fearful body sensations (to promote desensitization). Again, stress management programs tend to be more effective than simple RT for most psychiatric conditions.
12. Should patients be discouraged from the broad usage of relaxation techniques? Not at all! In addition to its role as a potentially valuable component in the treatment of anxiety and other psychiatric disorders, RT can be a potent means for relieving daily stress and attenuating

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psychophysiological stress responses (i.e., chronically exaggerated reactions to stressful stimuli in any of a variety of organ systems). It can be rewarding and effective in the alleviation of subclinical anxiety disorders, as an alternative coping response to self-destructive behaviors, as an adjunct to psychotherapy, and/or as a preventative to the accumulation of daily stress. In addition, data suggests that RT may be useful in the treatment of certain physical illnesses.

13. Relaxation training has been shown to be valuable in the treatment of which medical conditions? RT has been applied to a variety of medical conditions, with both positive and negative results (Gatchel and Blanchard, 1993; Murphy, 1996). The strongest and most positive effects are apparent in headache disorders. Both progressive muscle relaxation and electromyographic biofeedback are effective in promoting a clinically significant reduction in tension headache symptoms (50% reduction in self-reported symptoms) in approximately 40-50% of sufferers. However, cognitive therapy (identifying situations where headaches occur, improving recognition of the early warning signs of headache, and learning to practice relaxation skills immediately prior to headache onset) appears to be even more effective. Evidence suggests that cognitive therapy in combination with RT is more effective in reducing symptoms than amitriptyline. RT, especially autonomic-directed approaches (temperature biofeedback and autogenic training) also can alleviate migraine, though the effects generally are not as great in tension headaches. Nevertheless, temperature biofeedback in combination with autogenic training has been found to be as effective in promoting long-term reductions in migraine frequency as many pharmacologic approaches. RT may be of some benefit in low back pain and other chronic pain conditions (hypnotic interventions have been popular) and in reducing chronic insomnia. Again, however, more comprehensive, cognitive-behavioral programs are clearly the treatment of choice, and RT is best regarded as one component. Stress management programs promote significant and long-term clinical improvement in irritable bowel syndrome, but the degree to which the relaxation component contributes to these effects is not clear. In hypertension, bronchial asthma, and diabetes, research findings generally have been disappointing. Antihypertensive medications consistently produce more powerful results than RT. In asthma, RT improves pulmonary function, but the effects are small. In patients with Type 1 diabetes, RT does not lead to consistent, direct effects on blood glucose levels. (Effects in Type 2 diabetes are more equivocal.) Note, however, that RT in small subgroups ofpatients (e.g., highly anxious patients) with these types of illnesses may lead to significant clinical improvement.
Eficacy o f Relaxation Training
MEDICAL CONDITION DEGREE OF BENEFlT PREFERRED METHOD

Tension headache Migraine headache Chronic pain

** *

Chronic insomnia Irritable bowel syndrome Hypertension, bronchial asthma, diabetes

_ _ ~

Progressive muscle relaxation EMG biofeedback Autogenic training Temperaturebiofeedback Hypnosis Meditation EMG biofeedback Progressive muscle relaxation Meditation Progressive muscle relaxation Temperaturebiofeedback

** ***

Small, often transitory improvements,but not clinically significant Clinically significant, small effects Clinically significant, moderate effects Clinically significant, large effects

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14. Which is the most effective type of relaxation training? None of the forms can be considered most effective. Meditation is increasingly popular in hospital-based programs around the country, and indeed, for the management of cognitive anxiety, it often is an excellent choice (Kabat-Zinn, et al., 1992). However, in many patients somatic anxiety is paramount (e.g., chronic muscle tension). These patients typically do not respond well to the relatively unstructured directions for meditation (possibly experiencing relaxation-induced anxiety, see Question 19), and symptom-specific training is necessary (e.g. breath retraining). Progressive muscle relaxation-an easy and nonthreatening technique with concrete directions-is an excellent introduction to RT. It is especially useful in patients for whom somatic anxiety is central, helping to sensitize them to their own patterns of muscle tension. Biofeedback can be particularly effective as a reinforcer for further training. When immediate progress can be observed concretely (e.g., an on-screen display of a slowly increasing finger temperature), the skeptical patient may be more likely to appreciate the utility of relaxation.

15. Under what conditions are psychopharmacologicinterventions a better choice than relaxation training? Drug treatments and stress management approaches that include RT appear to have similarly potent, short-term effects in the treatment of anxiety. Long-term studies show that stress management training is somewhat more effective than psychopharmacologic intervention. In certain circumstances, however, medication is a better choice for initial treatment. For example, when anxiety is overwhelming, patients are unable to concentrate on RT tasks (or other stress management instructions). Psychopharmacologic agents may facilitate the introduction and use of RT at a later time. In addition, when time and/or finances are limited, referral for RT may not be practical. However, given the high relapse rates for anxiety conditions following the discontinuation of drug therapy, practitioners should be wary of limiting their intervention to drug treatments, especially when the presenting problem does not appear to be a transient condition. At the very least, inclusion of stress management interventions expands the patients range of coping strategies and significantly lowers the rate of long-tenn relapse.
16. Are relaxation tapes as clinically effective as live training? No. Live training has been shown to be consistently more effective than taped instruction in providing patients with the skills to lower physiologic arousal. In live training, the patient has the opportunity to benefit from an individualization of training and ongoing feedback. Interpersonal factors, especially the therapists involvement and warmth, also may be important contributors.
17. How important is home practice? It is essential. However, few differences are observed between those who practice daily and those who practice only occasionally, and frequency of home practice typically does not correlate with degree of clinical improvement. Thus, while home practice is necessary, extensive and regular practice is not necessarily more advantageous than occasional practice.

18. What are the best methods for encouraging home practice? Greater levels of self-efficacy (belief in personal success) and higher expectations of benefits are both associated with regular practice. Thus, the therapist may be most successful in promoting home practice by encouraging the patient to believe that RT is a worthwhile endeavor and that he or she can be successful at it. In addition, written prescriptions (detailing the specifics of practice duration, frequency, and timing) may effectively encourage home practice. 19. What is relaxation-induced anxiety? While adverse effects are uncommon, a subset of patients experience paradoxical sensations of transient anxiety when beginning RT. On rare occasions, severe anxiety may develop (referred to as relaxation-induced panic). Anxiety responses appear to be more common with cognitive forms of relaxation (e.g., meditation) than with somatic forms (e.g., progressive muscle relaxation). The causes of relaxation-induced anxiety are not clear, but cognitive factors (e.g., fear of losing control) as well as somatic factors (e.g., subtle hyperventilation) are suspected.

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In autogenic training, such responses (termed autogenic discharges) are not considered abnormal, and are thought to reflect the unloading of pent-up thoughts or muscular activity. A similar perspective is seen in many forms of meditation, where such anxiety is viewed as a too-rapid release, an unstressing, of emotional tension. Given the aversive nature of such responses, it is possible that relaxation-induced anxiety is a major contributor to the high dropout rate often seen in RT. However, in the hands of a skilled therapist, it may become a valuable part of ongoing training (as well as potentially useful in associated psychotherapy interventions) as the patient learns to relax and accept such experiences. Alternatively, the therapist can switch, at least initially, to a more structured form of relaxation (e.g., progressive muscle relaxation or biofeedback).
BIBLIOGRAPHY
1. Barlow DH: Cognitive-behavioral therapy for panic disorder. Current status. J Clin Psychiatry %(Supplement 2):32-37, 1997. 2. Benson H: The Relaxation Response. New York, Morrow, 1975. 3. Borkovec TD, Mathews AM, Chambers A, et al: The effects of relaxation training with cognitive or nondirective therapy and the role of relaxation-induced anxiety in the treatment of generalized anxiety. J Consult Clin Psycho1 55383-888, 1987. 4. Craske MG, Barlow DH: Panic disorder and agoraphobia. In Barlow DH (ed): Clinical Handbook of Psychological Disorders, 2nd ed. New York, Guilford Press, 1993. 5. Gatchel RJ, Blanchard EB (eds): Psychophysiological Disorders: Research and Clinical Applications. Washington, DC, American Psychological Association, 1993. 6. Kabat-Zinn J, Maisson AO, Kristeller J, et al: Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry 149:936-943, 1992. 7. Lehrer PM, Carr R, Sargunaraj D, Woolfolk RL: Stress management technqiues: Are they all equivalent, or do they have specific effects? Biofeedback and Self-Regulation 19:353401, 1994. 8. Murphy LR: Stress management in work settings: A critical review of the health effects. Am J Health Promo 11:112-135, 1996. 9. Suinn RM: Anxiety Management Training: A Behavior Therapy. New York, Plenum Press, 1990.

47. MEDICAL TREATMENT OF DEPRESSION

Russell G. Vasile, M.D
1. What symptoms are affected by antidepressant medications?
Antidepressant medications exert their effects on the psychological and neurovegetative physical symptoms of depressive illness. Psychological symptoms include feelings of sadness, hopelessness, helplessness, worthlessness, guilt, and suicidal ideation. Physical symptoms include lack of energy, trouble concentrating, insomnia or hypersomnia, appetite disturbance (with weight loss or, less commonly, weight gain), diminished interest and/or pleasure in daily activities, psychomotor agitation or retardation, diminished libido, increased anxiety and/or agitation, and impaired cognitive function.

2. What are the factors in clinical presentation that suggest prescription of an antidepressant medication? The diagnosis of major depression-persistent presence of five or more of the above physical features together with psychological symptoms, for a period of 2 weeks-is a strong indication for prescribing antidepressant medications. Additionally, there is evidence that the persistent presence of psychological symptoms even in the absence of marked neurovegetative depressive features may be sufficient indication to prescribe antidepressant medications. Thus, patients with dysthymia also are candidates.