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首页 Cognitive Behavioral Treatments of headache.pdf

Cognitive Behavioral Treatments of headache.pdf

Cognitive Behavioral Treatments…

上传者: 特才 2012-04-02 评分 0 0 0 0 0 0 暂无简介 简介 举报

简介:本文档为《Cognitive Behavioral Treatments of headachepdf》,可适用于人文社科领域,主题内容包含CognitiveBehavioralTreatmentsofheadache楊聖珊醫師南區頭痛讀書會BehavioralTreatments•Re符等。

CognitiveBehavioralTreatmentsofheadache楊聖珊醫師南區頭痛讀書會BehavioralTreatments•RelaxationTraining•BiofeedbackTraining•CognitiveBehaviortherapyStressManagementRelaxationTraining(放鬆)•放鬆是許多心靈療法的基礎•主要是靠調整呼吸和放鬆肌肉來達成。•有三種訓練放鬆的方法包括:持續的肌肉放鬆(progressivemusclerelaxation)自我調控(selfregulation)冥想沉思(meditation)。•有一項研究指出經過十個階段的漸進式放鬆訓練百分之九十六的頭痛患者可以有效降低頭痛發作的頻率、持續時間和嚴重度。頭痛電子報傑克遜放鬆法與漸進式肌肉放鬆法a傑克遜肌肉放鬆法-這套方法是由Jacobson一九三八年首先描述,在一九七年所設計出來的經由肌肉一緊一鬆交替的方式使身體每一處肌肉收緊和鬆弛藉此方法可以達到身心放鬆的目的。b漸進式肌肉放鬆法-練習步驟與前者大致相同唯一不同之處為身體局部逐漸放鬆不須先緊縮再放鬆。http:wwwyoutubecomwatchv=KxQJIiutK放鬆訓練•指溫升高,心跳緩和,肌肉放鬆,血壓降低,呼吸減緩,減少氧消耗•放鬆後神經訊息迴饋腦部•利用深而慢的呼吸達到深度放鬆•注意力集中,從規律的身體各部放鬆,而達到情緒的穩定再影響各種身體機能的運作。放鬆訓練Conceptualization(讓病人了解放鬆訓練的目標,原理,過程)Selfmonitor(對放鬆度,自我評分)Discriminationtraining(辨別體會放鬆時身體症狀,進一步以此身體感覺為放鬆訓練指標)RelaxationTraining(放鬆訓練)Transfertraininggeneralization(將學到的技巧於家中練習,應用於日常生活情境中)不斷的練習放鬆訓練體驗緊張與放鬆後的二種不同感覺,並且掌握要領,抓住放鬆後的內在感覺(Internalcue),(generalization)才能將它類化到日常生活情境Historyandclinicalapplicationsofbiofeedback•biofeedback(BFB)beganintheUSA,lates•instrumentaltrainingcouldproduceincreasesordecreasesinseveralbodyresponsesTheseincludedvasomotorresponses,bloodpressure,salivation,galvanicskinresponseandcardiacratesBehaviouraltreatments:rationaleandoverviewofthemostcommontherapeuticprotocolsNeurolSci():S–SLGrazzibiofeedback(BFB)•Individualscouldgainvolitionalcontroloverseveraldifferentautonomicfunctions•corticalcontrolwaspossibleoverautonomicnervoussystemactivity生物迴饋像鏡子一般•反應在我們面前讓我們不僅可瞭解並可進一步學習去控制、調整自己的生理狀態訓練自己達到身心放鬆的狀態。•解讀身心狀況,把它量化•臨床上最常用下列幾項指標:指溫-緊張時溫度較低放鬆時指溫升高。心跳-緊張時心跳快速放鬆時心跳緩和。EMG(肌肉活動電位)-緊張時肌肉緊繃放鬆時肌肉放鬆。精神官能症之行為治療李明賓李宇宙醫師著Biofeedback(BFB)•小孩和較年輕的病患對此種療法的反應較佳。•因為該種療法的療效已經被肯定有些學者認為它應該被視為預防偏頭痛的一種標準治療方式。TechniquesofBFBThemostcommonforms•Thermal(handwarming)訓練自我控制手指的溫度•ElectromyographicEMGbiofeedback:自我控制肌電波,尤其適合喜歡機器電子設備者•BVP–BloodVolumePulse•Neurofeedback(EEG)Frequency,durationofBehavioralTreatmentsBFBRequires:TrainedtherapistWeeklyminsessionsTwotothreemonthsCBT•hoursweek•(min)•week•timesrelaxationSession:ProgressiverelaxationSession:Cuecontrolled,briefrelaxation,differentialrelaxationSession:Applicationtrainingineverydaylifewhenfeelingtense,stressorheadachesPracticemindailySession:ProgressiverelaxationSession:Cuecontrolled,briefrelaxation,differentialrelaxationSession:Applicationtrainingineverydaylifewhenfeeling,tense,stressorheadachesPracticemindailyMinimumnumberofsessions:Schoolbasedrelaxation:sessionsamin,weekSession:groupswithsubjectsindividualtrainingComplementedwithmanuals,audiotapes(CD),hometrainingdaycognitivebehaviortherapy•基本假設為人的情緒與行為會被他的對自身或週遭事物的看法所決定。所以治療者澄清病患對這些看法的錯誤認知讓病患領悟到這些看法如何造成自己情緒的問題認知治療理論•Beck的認知治療•Ellis的理性情緒治療•Meichenbaum的自我教導訓練•在年代AlbertEllis理性情緒治療法(rationalemotivetherapy)(如今重新命名為理情行為治療法簡稱REBT)。•認知治療是一種有系統的心理治療方式它的基礎是情緒障礙理論(Beck,)、心理學的實驗與臨床的研究(KovacsBeck,)以及界定清楚的治療技術(Becketal,)。認知治療也是一種結構式的心理治療用來幫助病人減緩症狀並且學習有效的方式來處理病人所遭遇的困難。•而Mahoney和Meichenbaum()也都認為認知行為治療法的出現象徵著認知學派和行為學派有了極為成功的結合。Perris()更指出認知治療和行為治療在一開始就共同結合的現象已經證實了治療的成果。Ellis歸納的種常見非理性思考模式每個人都需要得到身邊親友的喜愛與讚美每個人都要能力十足,多方面有成就才有價值對危險及可怕的事ㄧ定要非常掛心逃避困難與責任比面對他們容易有些人是不好的,邪惡的,卑鄙的期待的沒實現是可怕的災禍不幸不快樂都是外在引起的,個人無能為力每個人都要有靠山才行過去的經驗會決定影響現況每個人都應要為別人的問題與適應不良感到難過每個問題都只有一個正確答案,必須找到才行認知治療者常依循下列五步驟:()注意去發現病人常出現的那些負面想法。()讓病人瞭解他的負面想法如何影響他的情緒變化與行為反應。()找出證據來證實病人的想法是無根據或不合真實的。()使病人學習採用另一種新的、真實的看法來取代他原本所採用的負面的、悲觀的、不合理的想法。()找出使病人容易產生負面想法的內在錯誤信念、假設或思考方式並加以修正。家庭作業•ㄧ式三欄的認知記錄•第一欄:發生的時間地點塲合,頭痛焦慮程度評分•第二欄:記下當時過程前後想法,推理•第三欄:嘗試分析來龍去脈的錯誤邏輯•可能的話增列第四欄:寫出可能替代性的想法,重新歸因家庭作業ㄧ時間地點塲合,頭痛焦慮程度評分二前後想法,推理三分析來龍去脈的錯誤邏輯AM於辦公室頭痛分焦慮分•我今天特別虛弱,所以……•我今天不應該上班…•女友回台北,所以…•我想我會死…今天身體很好,只是工作太多想把事情做得完美不是事實,不是最糟狀態技巧打破砂鍋問到底:證據何在還有其他可能嗎發生了又怎樣•可以自問自答,最好自言自語(行話)•勿恨鐵不成鋼(而是教病人如何察覺自己臨事或對自己所持有的自動化思考automaticthinking)(行話)有什麼證據可以支持或駁斥這個看法理由何在這樣因果關係是否太簡單了這樣想是習慣使然還是事實這樣想會不會離事實太遠事實真的如所說的嗎要不是這樣,就非那樣不可嗎這樣遣詞用句會不會太極端所引據的是否僅限於合己意的特例有沒有使用認知的自我防衛機轉消息來源可靠嗎會不會傾向將可能性當必然性這樣的想法較憑感覺而昧於事實嗎會不會執著與事實毫不相干的情境中實演•病人:每次開會時就會頭痛(trigger)•治療者:開會時是怎樣狀況•病人:開會時,很痛苦,怕出錯,很緊張好像再怎麼努力,也無法達到完美•治療者:從以前到現在有發生什麼大的錯誤嗎•病人:……嗯,也沒有•治療者:也沒有事情搞砸了,那你會不會把事情想的嚴重了ㄧ點•病人:……嗯,也許吧•治療者:看起來,你在太多事情,太多難處理的情況下,若想要做的完美,會有不舒服出現,就會頭痛你的身体會出現這樣感覺,壓力來時會這樣反應是不是你自己想ㄧ個辦法,試試歸類,記錄在什麼狀況,會有什麼感覺,什麼樣的念頭ㄧ週後回診,病人交記錄報告•練習放鬆訓練學到的技巧於家中練習下週回診,病人交記錄報告•治療者:若於上班時要趕報告,坐辦公桌前,試試放鬆訓練分鐘•病人回診回應說:沒效•治療者:檢討是否做了正確的放鬆訓練加上thermalbiofeedback機器量指溫發現,雖做了正確放鬆訓練,但沒放鬆重新再教ㄧ次,直到學到真正放鬆叫病人回家中不斷再練習•學會了有用的方法,每次壓力來時,每次做有效雖然還有頭痛,但以從分降到分•病人可接受,認為是一個有幫忙的方法Forwhompatientpreferencepoortolerancepoorresponsetopreventivemedicationsmedicalcontraindicationstomedicationspregnancy,plannedpregnancyornursinghistoryofoveruseofacutecaremedicationssignificantstressordeficientstresspaincopingstrategiesHaveinsufficientornoresponsetopharmacologicaltreatmentIntegrationofbehaviouraltechniquesintoclinicalpracticeNeurolSci():S–SDOIsREWeeksWhatdoestheevidenceshowEfficacyofbehaviouraltreatmentsforrecurrentheadachesinadultsFAndrasikNeurolSci():S–SDonotreceivetreatmentduetotheexpenseoftreatmentInabilitytotraveltoclinicFrustrationwithpasttreatmentPromisingtreatmentvenuesincludelimitedcontactandhomebasedtreatmentformats,aswellasdeliveryoftreatmentsinschoolsandworksitesorviatheInternetandothermassmediaBehavioralApproachestotheTreatmentofMigraineKennethAHolroyd,PhD,andJanaBDrew,PhD,Andforwhom:complicationsthatsuggestmedicalreevaluationreadingcomprehensionbelowthgradeforlimitedcontacttreatmentcognitiveimpairmentcomorbidpsychiatricdisorderofsufficientseveritytoimpairthepatient’sabilitytoparticipateintreatmentPSYCHOLOGICALSYMPTOMSBehavioralApproachestotheTreatmentofMigraineKennethAHolroyd,PhD,andJanaBDrew,PhD,NotforwhomDifficulttotreatbybehaviouralapproachesMedicationoveruseRefractoryheadachesChronic,dailyandunwaveringpatientsCluster(Blanchard,Andrasik,Jurish,Teders,),posttraumatic(RamadanKeidel,),Druginduced,unremitting,andpossiblymenstrualmigraine(seeHolroyd,Penzien,Lipchik,)NeurolSci():S–SAppliedPsychophysiologyandBiofeedback,Vol,No,June(C)DonaldBPenzien,JeanettaCRains,andFrankAndrasikCoordinated,interdisciplinarycare,suchasthatfoundatmostcomprehensivepaincenters,mayberequired(Duckro,Tait,Margolis,Silvermintz,Lake,Saper,Madden,Kreeger,)Childrenrespondatagreaterlevel(seearticlebyHermannBlanchard,thisissue)ElderlypatientscanrespondatlevelsreportedintheearlierdescribedmetaanalysesifcertainproceduraladjustmentsaremadetoaccommodateforanyphysicalorcognitivelimitationspresentBehavioralManagementofRecurrentHeadache:ThreeDecadesofExperienceandEmpiricismAppliedPsychophysiologyandBiofeedback,Vol,No,June(C)DonaldBPenzien,JeanettaCRains,andFrankAndrasikrespondwellBehaviouraltherapies(When)•facetoface,weeklyclinicsessions•nofirmstandard•Duration:dependsontheclinicalresponseofsymptomrelieforthepatient’sadequatecontrolofthetargetmeasure•diminishingreturns,suchasresponseplateaus,thenthepractitionershouldterminatefurthertreatmentBehaviouraltreatments:rationaleandoverviewofthemostcommontherapeuticprotocolsNeurolSci():S–SDOIsLGrazzi•cognitivebehaviouralpainandstressmanagementstrategiesthatfocusonthereactivecomponentofthepainexperiencePatientslearntoidentifyandmodifydistressrelatedthoughtsandmaladaptivestylesofthinkingthatcancontributetoheadachesusceptibility#Thistypeoftherapyemphasisestheroleofthoughts,perceptions,beliefsystems,selfevaluationsandappraisalsthatinfluenceemotionalstates,physiologyandbehaviour#problemsolvingandcopingskillsPositiveselfstatements•Patientsrehearseadaptivecognitiveandbehaviouralresponses•Selfstatementshelppatients()prepareforanattack,()manageinitialsymptoms,()handlecriticalmomentsduringtheattackand()actadaptivelyduringthepostheadachephase#Patientsbecomekeenobservers,preparetocopeadaptivelyandavoidbecominghypervigilanttopainsensations•Cognitivetherapyinvolvesmodifyingapatient’sautomaticinternaldialogueIntegrationofbehaviouraltechniquesintoclinicalpracticeNeurolSci():S–SDOIsREWeeksTreatmentmodalities•Relaxationtraining•Temperaturebiofeedback•Tempbiofrelaxation•EMGbiofeedback•Cognitive‐behavioraltx•CBTtemperaturebiof•Waitlistcontrol•OthercontrolsGoals(ofnonpharmacologicaltreatment)reducedfrequencyseverityofheadachereducedheadacherelateddisabilityreducedrelianceonpoorlytoleratedorunwantedpharmacotherapyenhancedpersonalcontrolofpainreducedheadacherelateddistressandpsychologicalsymptoms•mostinstancestheseinterventionsemphasizepreventionofheadacheIntegrationofbehaviouraltechniquesintoclinicalpracticeNeurolSci():S–SDOIsREWeeksALTERNATETREATMENTFORMATS(FORBEHAVIORALINTERVENTIONS)MinimalTherapistContactTreatmentorhomebased(selfregulationskillsareintroducedintheclinic,buttrainingprimarilyoccursathomethreeorfourclinicsessions,oftenasmanyas–weeklysessions)limit:tominuteslongforindividualsortominutesforgroupsHome:weektherapistadministeredformatoranweekhomestudy)GroupTreatment(Theimprovementindividually)SelfHelpTreatment(headachereductionwiththeirselfhelpprogramversusonlywithinformationcontrol,)InternetandMassCommunicationsTreatmentsBehavioralManagementofRecurrentHeadache:ThreeDecadesofExperienceandEmpiricismAppliedPsychophysiologyandBiofeedback,Vol,No,June(C)DonaldBPenzien,JeanettaCRains,andFrankAndrasikAdvantagesofbehaviouraltreatmenttoChronicmigraineaccompaniedbymedicationoveruse•behaviouraltreatmentmedicalcare>distinctadvantage•yearfollowupevaluation:similarresult•yearfollowup,thecombinedtreatmentgroupshowedadistinctadvantage•Thosereceivingbehaviouraltreatmentrecordedfewerdaysofheadache,reportedlessconsumptionofanalgesics,andevidencedlessrelapsethanthosereceivingmedicationalone(vs)•SideeffectsandcomplicationsareminimalNeurolSci():S–SShortcomingsofbehaviouralTxRelativehighcostduetothenumberofpatient–therapistcontactsspecialequipmentandthetrainingneededMoretimeefficientandcosteconomicalplatformsNeurolSci():S–SimprovementrelaxationbiofeedbackcognitivebehavioraltherapyMigraine–(yrfu)TensionTypeHeadache–>ChildhoodMigraine(AComplementaryandAlternativeApproach)ThomasKKoch,MD•過去曾經有小型的研究認為特定的訓練對於特定的頭痛比較有效例如肌肉訓練(EMGbiofeedback)對於緊縮型頭痛有效指溫訓練(thermalbiofeedback)對於偏頭痛比較有效。•現在則是認為不管是使用什麼樣的生物回饋訓練只要能夠達專注、放鬆的效果就會有效。•例如指溫的訓練不論是訓練指溫升高或是下降效果都一樣不會因為訓練是增加血液的血流量或是減少血液血流量而有不同。•現在一般認為偏頭痛發生的原因是三叉神經的發炎。放鬆的訓練不只是減少憂鬱與焦慮也會透過情緒影響免疫功能的機轉穩定免疫系統減少引發偏頭痛的神經發炎產生所以可以有效預防偏頭痛減少頭痛的次數與嚴重度。頭痛電子報期HAreductionMigraineTensionTypeHeadacheHA(migraineTTH)BehavioramitriptylineBehaviortherapy‐toCombinedtherapy(RxB)BiobehavioralTreatmentofHeadacheRescuingPatientsfromIntractablePainEricSchuman,MPAS,PA‐CPortland,OregonAppliedPsychophysiologyandBiofeedback,Vol,No,June(C)NeurolSci():S–S•Behavioralinterventionsyielded‐reductionsinmigrainevsreductionfornotreatmentcontrolsTTH:Behavioralinterventionsyieldedtoreduction,comparedtoreductionfornotreatmentandforothercontrolsEvidenceBasedSupportPreventionofMigraine(USHeadacheConsortiumrecommendationsforbehaviouraltreatmentofmigraine)GradeAEvidenceRelaxationtraining,thermalbiofeedbackwithrelaxation,electromyographicbiofeedbackandcognitivebehavioraltherapymaybeconsideredastreatmentoptionsforpreventionofmigraineGradeBevidence:BehaviouraltherapymaybecombinedwithpreventivedrugtherapytoachieveaddedclinicalimprovementformigraineSummaryandconcludingremarksRelaxation,biofeedbackandcognitivetherapyleadtosignificantreductionsinheadacheactivity,rangingfromtoConversely,nonrespondersorpartialresponders(approximately–)Improvementsforbehaviouraltreatmentsexceedthoseobtainedforvariouscontrolconditions(waitinglist,medicationplacebo,psychologicalplacebo)BehaviouraltreatmentsproducebenefitssimilartothoseobtainedforpharmacologicaltreatmentsCombiningvariousbehaviouralandpharmacologicaltreatmentscanincreaseoveralleffectivenessEvidencefromthemetaanalysessuggeststhattheeffectsforbehaviouraltherapiesendureovertime(uptosevenyearsposttreatment)NeurolSci():S–SStrategiesofbehaviouralTxIdentificationofHAtriggers>UseselfregulationskillsAimedatpreventionofheadacheepisodesoptimaloptionsforyoungpatientsorforpatientswherethemedicationsremaincontraindicatedBehaviouraltreatments:rationaleandoverviewofthemostcommontherapeuticprotocolsNeurolSci():S–SLGrazzi•Headacheisacomplexproblemthatoftencanrequireamultidimensional,multidisciplinaryapproach•headaches(especiallymigraine)arehighlyprevalentandaffectnotonlyindividualpatients(andtheirfamilies),butalsosocietyatlarge•Thegoalistotreatthepersonandnotmerelypain•ItshouldbeemphasisedthatnonpharmacologicaltreatmentisnotantipharmacologicalIntegrationofbehaviouraltechniquesintoclinicalpracticeNeurolSci():S–SREWeeksTheENDThankyouforyourattentionFigCombinedmetaanalysesofbehaviouralandpharmacologicaltreatmentsfortensiontypeheadachePercentimprovementscoresbytreatmentconditionPortionsadaptedfromPenzienetalReproducedwithpermissionfromSpringerPublishingFigCombinedmetaanalysesofclinicandlimitedcontactbehaviouraltreatmentsformigraine,mixed,andtenotypeheadachesPercentimprovementscoresbytreatmentconditionPortionsadaptedfromPenzienetalReproducedwithpermissionfromSpringerPublishingAmitriptylineFigCombinedmetaanalysesofminimalcontactbehavioraltreatmentsformigraineandtensiontypeheadache:PercentimprovementscoresbydiagnosisandtreatmentconditionFigCombinedmetaanalysesofbehaviouralandpharmacologicaltreatmentsformigrainePercentimprovementscoresbytreatmentconditionPortionsadaptedfromPenzienetalReproducedwithpermissionfromSpringerPublishingrelaxationtraining•decreaseheadachebyenablingheadachepatientstomodifytheirownheadacherelatedphysiologicalresponsesanddecreasesympatheticarousal•Types:progressiverelaxationtraining,autogenictrainingandpassiveormeditativerelaxation•RelaxationtechniquesareoftenusedincombinationwithBFBandstressmanagementPSYCHOLOGICALSYMPTOMS•Depressionandanxietyarecomorbidwithmigraine(seeRadatandSwendsenforreview)butnostudieshaveexaminedtheimpactofmajordepressivedisorderonbehavioraltreatmentoutcomeCliniciansgenerallyagreethatwhendepressionissevere,behavioraltreatmentwillbedifficultand,further,thataddressingthemooddisorderthroughpsychologicalandordrugtherapy(ifpossibletherapiesthatalsoareeffectivewithmigraine)shouldbetheprimarygoalBehavioralApproachestotheTreatmentofMigraineKennethAHolroyd,PhD,andJanaBDrew,PhD,REFRACTORYHEADACHES•PatientswithheadachesthathaveprovenrefractorytomultipletreatmentspresentanobvioustreatmentchallengeAndrasikreviewsthehandfulofstudiesthathaveaddedbehaviortreatmenttodrugtherapywithrefractoryheadaches,concludingthattheadditionofbehavioralinterventionscanhelppatientswhohavenotrespondedtosinglemodalitytreatmentForexample,astudythatexaminedaninterdisciplinarygrouptreatmentapproach(medicationmanagement,physicaltherapy,education,relaxation,andbiofeedback)forpreviouslyintractableheadachefoundthatmorethanofpatientsexperiencedaorbetterreductioninheadachesfurther,therewasanaveragereductioninmedicationuseofBehavioralApproachestotheTreatmentofMigraineKennethAHolroyd,PhD,andJanaBDrew,PhD,MEDICATIONOVERUSE•Thereisevidencethat,incombinationwithamedicationwithdrawalprogram,behavioralinterventionscanbehelpfulinthelongtermmanagementofmedicationwithdrawalheadachesGrazziandcolleagues•itsuggestsbehavioralinterventionsmayhelppreventrelapse,possiblybyprovidinganalternativetoacutemedicationuseduringperiodsofheadacheexacerbationsBehavioralApproachestotheTreatmentofMigraineKennethAHolroyd,PhD,andJanaBDrew,PhD,•First,relaxation,biofeedbackandcognitivetherapyleadtosignificantreductionsinheadacheactivity,rangingfromto•Second,conversely,thereareafairnumberofpatientswhoarenonrespondersorpartialresponders(approximately–)#Predictionoftreatmentresponseandcarefultreatmentplanningbecomeparticularlyimportantwhenattemptingtoimproveuponthisoutcome#Certainheadachetypeshaveproventobeparticularlydifficulttotreatbybehaviouralapproaches(thosecharacterisedbymedicationoveruseandapresentationthatischronic,dailyandunwavering,andthosediagnosedasclusterorposttraumaticWhatdoestheevidenceshowEfficacyofbehaviouraltreatmentsforrecurrentheadachesinadultsFAndrasikNeurolSci():S–SDOIsResultsBFBandbehaviouraltrea

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