Patient interpersonal factors and the therapeutic alliance in treatments for bulimia nervosa
Abstract
Although the therapeutic alliance is robustly associated with psychotherapy outcomes,less is known about factors that
influence its development. This study examined the association between baseline patient interpersonal factors and patient-
rated alliance in a randomized trial comparing cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)for
bulimia nervosa. Using hierarchical linear modeling, early and middle alliance were negatively associated with interpersonal
distress and positively associated with interpersonal affiliation. Middle alliance was also related to treatment group
interactions with rigidity, affiliation, and control. Overall, alliance growth was higher in IPT than CBT. Using group-based
trajectory analysis,three divergent alliance trajectories emerged (high and improving,low and improving, and low and
stable), with group mean differences between two of them in terms of interpersonal distress and hostile-submissiveness.
The role of common factors in residential cognitive and interpersonal therapy for social phobia: A process-outcome study
Abstract
This study examined the role of common factors in residential cognitive therapy (RCT) and residential interpersonal
therapy (RIPT) for social phobia. Eighty social phobic patients were randomized to lo weeks of RCT or RIPT. Patients and
their individual therapists completed process and suboutcome measures weekly. The ratings were examined using linear
mixed models. Most patient-rated process variables showed U-shaped (quadratic) patterns over the course of treatment.
Therapist-rated alliance increased linearly. Therapist-rated first-week alliance and empathy predicted improvement in social
role security overthe course of therapy. The weekly fluctuations in common process predicted subsequent fluctuations in
suboutcomes in seven of 10 possible cases, whereas suboutcomes predicted process in four cases. The results support the
causal role of common factors.
ーーーーー
Psychotherapies consist of both specific and com-
mon factors, of which both, one, or neither may be
remedial. Common-factor models of psychotherapy
assume that what bothers people seeking therapy
(psychiatric symptoms and demoralization thatin-
cludes a negative view ofthe self and interpersonal
difficulties) are changed primarily or even exclusively
through common factors such as the therapeutic
alliance (Wampold, 2001). Contextual models differ
from common-factor models primarily in thatthey
assume that specific factors (e.g., cognitive restruc-
turing in cognitive therapy [CT]) are also required in
orderforthe common factors to be effective (Frank
& Frank,1991). The present study examines the role
of common factors in cognitive and interpersonal
therapy for social phobia. We have selected factors
that are emphasized in common-factor and contex-
tual models: alliance, empathy, and expectations of
treatment outcome (e.g., Frank & Frank,1991).
The therapeutic alliance can be understood as
consisting ofthree elements: agreement between the
patient and therapist on the tasks oftherapy, agree-
ment on the goals oftherapy, and the bond between
patient and therapist(Bordin,1979). The alliance is
also relevantin group therapy as the bond and
teamwork among the group members (Tschuschke
& Dies,1994). Empirically, both U-shaped (high-
low-high) quadratic and linear growth patterns
during the course oftherapy have been found
(Fitzpatrick,Iwakabe, & Stalikas, 2005). Most
studies showing a positive relationship between the
alliance and outcome (Orlinsky, Rennestad, & Will-
utzki, 2004) have measured these constructs in
overlapping time periods, precluding inferences
abouttemporal and causalrelationships between
them (Feeley, DeRubeis, & Gelfand,1999). How-
ever, using mixed-effects growth-curve analyses,
Klein et al.(2003)found thatthe early alliance
predicted subsequentimprovementin depressive
symptoms in a large sample of depressed patients.
Therapist empathy may be defined as the thera-
pist's willingness and capacity to understand the
client's thoughts,feelings, and concerns (Rogers,
1980). Most studies of various types of psychother-
apy have supported the hypothesis that empathy is
related to outcome (Orlinsky et al., 2004), but again
overlapping time periods in most studies preclude
inferences regarding the causal direction between
empathy and outcome. Using a structural equation
modeling approach. Burns and Nolen-Hoeksema
(1992)found results consistent with a causalinflu-
ence oftherapist empathy on outcome in cognitive-
behavioraltherapy of depression.
Frank and Frank (1991) asserted that a loss of
hope characterizes persons seeking help for emo-
tional problems and thatthe powerto install
optimism and expectations thattherapy will help
was a crucial common factor across psychotherapies.
This hypothesis has been supported in several
correlational studies (Orlinsky et al., 2004).In a
cognitive-behavioral group therapy of social phobia,
Safren, Heimberg, and Juster(1997)found that
expectations measured after a presentation ofthe
cognitive-behavioral model of social phobia in the
first session predicted outcome.
With respectto the relationship between the
common factors emphasized by Frank and Frank
(1991),therapeutic alliance has been shown to
mediate the influence of expectations on outcome
among depressed patients (Meyer et al., 2002).
In most studies of common process,the process
variables have been assessed once ortwice in early
therapy. The initiallevel of, orinitial change in,the
process variables have then been related to outcome
during the entire course oftherapy. This approach
can potentially sufferfrom ambiguities concerning
the time precedence ofthe process variable. Further-
more, a multitude of stable external, personality, and
measurementfactors may explain the covanance
between alliance and outcome. Standard regression
has typically been used to analyze the data. Un-
fortunately,this method does not separate the
predictors'relationship to the initiallevel of
the outcome measure from its influence on change
scores. Furthermore,it cannot accommodate long-
itudinal correlated data.
Moreover,the concept of process implied in this
approach is limited in scope. Therapeutic process
might be better denoted as specific events and
experiences occurring in and between therapy ses-
sions and having ratherimmediate effects on out-
come (Orlinsky et al., 2004). Forinstance, changes
in expectations during therapy may well have rapid
effects on symptoms that could be observed after
days ratherthan weeks or months. Studying the
influence of specific events on outcome usually
require statistical approaches that accommodate
longitudinal data that are correlated overtime.
To address both aspects of process, we measured
process and outcome repeatedly throughouttherapy.
We then modeled the effects ofthe initial and the
ongoing process on subsequent suboutcomes. This
allowed us to study both week-to-week changes and
the effects of early process that might extend overthe
course oftherapy. The weekly suboutcome measures
used in this study were selected to reflectthe overall
aims ofthe therapies: social anxiety reduction and
improved socialrole security. They were also con-
sistent with the types of outcomes emphasized in
contextual models:restoration of morale,including
an improved self-view and improved interpersonal
functioning, as well as the alleviation of symptoms.
The suboutcome measures were also correlated with
the overall outcome measures to ensure thatthey
were related to treatment outcome. The treatments
were delivered in a residential setting. Although this
is notthe typical venue of most psychotherapeutic
treatments,the concept of common factors in
psychotherapy would imply thattheir effects would
be presentregardless of setting.
We have reported the overall outcome results in
our sample of social phobic patients in another study
(Borge et al., 2008).In brief,the patients in both
conditions@residential cognitive therapy (RCT)
and residential interpersonal psychotherapy
(RIPT)@showed robustimprovements from pre-
to posttreatment and continued to improve in the 1-
yearfollow-up period. The number of clinically
significantly improved patients was 25 (31%) at
posttreatment and 38 (48%) atfollow-up. There
were no differences in outcome between RCT and
RIPT from pre-to posttreatment orfrom pretreat-
mentto follow-up on the overall outcome measures.
However, RCT patients improved more during
treatment on one oftwo weekly outcome measures
(see Method section). Patients rated RCT and RIPT
as equally credible.
The purpose ofthis study was to examine the
effects ofthe selected common factors in these
therapies. Specifically, we soughtto address the
following questions:
What were the change patterns ofthe common
process variables during the course oftherapy?
Were the changes in the common process
variables more influenced by one ofthe treat-
ments?
Which ofthe common process variables pre-
dicted treatment outcome from theirlevels in
early therapy?
Did the week-to-week fluctuations in the
common factors impact subsequent weekly
outcomes?
Did the common process variables have the
same effects in both treatments?
Did weekly fluctuations in the alliance mediate
the relationship between weekly fluctuations in
expectations and outcome?
Did the week-to-week fluctuations in weekly
outcome measures impact subsequent weekly
process?
教科書的IPT解説 Interpersonal Therapy for Bulimia Nervosa
IPTについての大変良い入門的概説と思うので長いが採録
Interpersonal Therapy for Bulimia Nervosa
Robin F. Apple
Stanford Medical Center
Department of Psychiatry
Interpersonal therapy (IPT) has been identified as an effective treatment
for bulimia nervosa that does not focus on bulimic symptoms. Rather, a
detailed assessment culminating in an "interpersonal inventory" identifies
core associated interpersonal problem(s) that become the focus of treat-
ment. For that reason, IPT may be particularly helpful for clients who have
become "stuck" in their eating disorder for reasons associated with prob-
lematic relationships.IPT is also helpful for clients who may benefit from a
therapy that offers some structure,focus, and containment without clear
behavioral directives. This article describes the theoretical background,
structure, and technical aspects of IPT and presents a bulimia nervosa
case in which IPT was used effectively,in part due to a "goodness of fit"
between the issues presented by this particular client and the treatment
model. The case also illustrates IPT's approach to handling resistance and
therapist/client relationship issues.
Since its debut as an option for treating bulimia nervosa,interpersonal therapy (IPT)
has been recognized as one of a handful of effective psychotherapies for this hard-to-treat eating disorder. Moreover,IPT compares favorably with the currently accepted "treatment of choice"--cognitive-behavioraltherapy (CBT)(Fairburn,1997; Fairburn, Jones,Peveler, Hope, & O'Connor,1993). Originally conceptualized forthe treatment of
depression (Klerman, Weissman, Rounsaville, & Chevron,1984),IPT has since undergone
subtle revisions that have facilitated its application to a wide variety of psychological
disorders such as panic disorder, somatization disorder, and a number of others.(For a
complete review, see Weissman & Markowitz,1994).
THEORY AND CONTENT OF IPT
As this article will discuss,IPT provides an alternative to treating bulimia nervosa that
does not focus directly on the eating disorder symptoms.Instead,through a comprehensive assessment of the client's history,it allows for identification of key "underlying"
problem areas that have contributed to the eating disorder overtime. The rationale of IPT
for bulimia suggests that those who develop the disorder typically exhibit a number of
interpersonal problems of which they may be unaware. These may include, among others:
conflict avoidance, difficulties with role expectations, confusion regarding needs for
closeness and distance, and deficits in social problem solving.
Frequently associated with these interpersonal problems are deficits in affect
regulation. Many bulimics describe a range of emotions including depression, anxiety, and
loneliness--which are commonly identified as binge triggers. Often through encouragement to work through the core interpersonal problem areas,IPT may also enable bulimics
to modulate the emotional states that perpetuate their eating-disordered behavior. The
time required for the therapy to effect changes in relationships and associated affects
might explain why IPT,in comparison with a more directive and symptom-focused treat-
ment like CBT,is slower to take action, but may reap benefits that are equally long lasting
(see Fairbum,1997.for a review).IPT is also an appealing choice for those who respond
more favorably to gentle encouragement or experimentation than to more directive behav-
ioral prescriptives.
IPT theory is based on the work of early interpersonalists such as Sullivan (1956).
The theory purports an association between certain broad interpersonal problem areas
(for example,role transition, grief,role disputes, and interpersonal deficits) and the devel-
opment, perpetuation, and exacerbation of a symptom or condition. Across disorders,IPT
has remained a time-limited (usually 24 to 36 weeks) and focused integration of com-
monly used techniques associated with other therapeutic approaches. These include open-
ended questioning,role plays, examination of advantages and disadvantages of change,
and encouraging expression of feelings.
IPT is both similar to and different from the theories and therapies from which it has
borrowed its techniques. For example, unlike psychodynamic therapies,IPT retains a
primary focus on "here and now" interpersonal relationship issues outside of the therapy
room. Past relationships are examined only to ascertain the origins of current problem
patterns in attitudes, expectations, communication, or behavior and the therapist-client
relationship is addressed sparingly. Unlike cognitive-behavioral therapies,IPT does not
include either systematic approaches to change problematic thoughts or beliefs or home-
work for practice and rehearsal of new skills.
STRUCTURE AND FORMAT OF IPT
First Phase
IPT is conducted in three fairly distinct phases. The first phase, history-taking and assess-
ment,lasts between three and five sessions. The objectives of this phase include identi-
fying the primary problem area(s) to be addressed and introducing clients to an
interpersonal rationale for understanding their eating problems.Initially, a thorough review of
the patient's current relationships (for instance, number,type, quality, and degree of
reciprocity) sheds light on the current issues linked to the disordered eating behaviors.
Then,to establish associations between the onset and exacerbation of the symptoms
overtime,four areas are traced chronologically from the client's earliest memories to the
present:
(i) significant life events,(ii) mood and self-esteem,(iii)interpersonal relationships, and
(iv) changes in weight. From the review of current and past relationships and experi-
ences,the client creates an interpersonal inventory or "life chart" that usually provides a
clear illustration of the nature of interrelationships between certain life experiences and
bulimic symptoms. As these associations are made clear, clients can begin to consider the
role of underlying issues in determining the course of their eating disorder and under-
stand more clearly the rationale of IPT. Once the life chart is completed,the therapist and
client conclude the assessment phase by coming to an agreement about the primary prob-
lem area(s) to be addressed for the remainder of treatment.
As described above,IPT specifies four general problem areas that comprise the range
faced by most individuals requesting psychotherapy:role transition,interpersonal role
disputes, grief, and interpersonal deficits. Based on the assessment, one or more catego-
ries are chosen as the primary treatment focus. The categories are broad and flexible so
that therapists can devise an individualized formulation for each client. Therapy goals,
and to some extent techniques, are determined by the problem area(s) identified as pri-
mary. For example, a focus on successfully navigating a role transition (for example,
moving away from home to start college) would entail helping a client to: clarify the
meaning of the transition;identify the advantages, disadvantages, and perceived obsta-
cles to navigating the transition; express feelings about moving from the old to the new
role; anticipate and practice skills and establish necessary supports. Klerman et al.(1984)
present a complete description of problem areas,therapy goals, and techniques.
Middle Phase
Once the assessment phase is concluded,the middle phase of therapy begins with the
therapist "steering from behind" as the client initiates discussion of material related to the
agreed-upon problem area(s). The goals during this phase are particular to the identified
problem areas. For example, a few of the goals of therapy when role transition is a
primary problem include exploring the meaning of moving from one role to another,
expressing the associated affects such as grief, anxiety, or excitement, and developing the
skills and supports required in the new role.In IPT,the client is encouraged to avoid
detailed discussion of eating behaviors in favor of exploring the interpersonal context in
which they occur. Prolonged discussion of symptoms is viewed as potentially distracting.
Final Phase
The final phase of treatment involves summarizing and consolidating gains, anticipating
future problem areas, and thinking through solutions. At the end of treatment, clients are
encouraged to discuss specific changes in their eating behaviors, particularly as they
relate to improvements in relationship patterns.
The case that will be presented here was based on a manualized from of IPT for
bulimia nervosa, developed for a multicenter bulimia nervosa treatment study comparing
IPT and CBT (see Fairbum,1993). Some modifications were made to adapt IPT for
treatment of bulimia nervosa; others were designed to enable clearer comparisons with
CBT in this study. First,the assessment phase included a history of eating disorder symp-
toms and changes in weight. Second, after completion of the assessment phase, every
therapy session concluded with a nonspecific recommendation for change,for example:
"If you find an opportunity to work on issue X during the week,feel free to take it."
Third,the treatment format consisted of 19 sessions over 20 weeks (twice weekly for two
weeks, weekly for12 weeks, and biweekly for three weeks). Finally attempts were made
to limit patients' discussion of their disordered eating behaviors to 10 seconds or less.
このあと39歳女性Saraのcase report。お世話をする人。15歳でファッションモデルをしていたときに過食が始まった。
ambivalent という語が出てきておもしろい。
A RANDOMIZED TRIAL OF INTERPERSONAL THERAPY VERSUS SUPPORTIVE THERAPY FOR SOCIAL ANXIETY DISORDER
SADに対してのIPTとサポーティブの比較検証
どちらもいいと書いてある
優しい論文である
There were also no differences in proportion of responders between IPT and ST. Only for a scale measuring concern about negative evaluation (Brief Fear of Negative Evaluation Scale) was IPT superior.
Metacognitive Interpersonal Therapy in a Case of Obsessive-Compulsive and Avoidant Personality Disorders
Metacognitive interpersonal therapy (MIT)for personality disorders is
aimed at both improving metacognition--the ability to understand
mental states--and modulating problematic interpersonal representa-
tions while building new and adaptive ones. Attention to the
therapeutic relationship is basic in MIT. Clinicians recognize any
dysfunctional relationships with patients and work to achieve
attunement to make the latter aware of their problematic interperso-
nal patterns. The authors illustrate here the case of a man suffering
from obsessive-compulsive and avoidant personality disorders with
dependent traits. He underwent combined individual and group
therapies to (a) modulate his perfectionism,(b) prevent shifts towards
avoiding responsibilities to protect himself from feared negative
judgments, and (c) help him acknowledge suppressed desires. We
show how treatment focused on the various dysfunctional personality
aspects.
ーーーーーーーー
MITについてまず短い説明
Metacognitive interpersonaltherapy (MIT; Dimaggio, Semerari, Carcione,
Nicolo, & Procacci, 2007) appears suited to tackling the problems arising from the
copresence of distinct PDs. Metacognitive interpersonal therapy aims to define PD
prototypes with their multiple facets. For each disorder, MIT describes
(a)the predominant forms of subjective experience and their shifts, and
(b)the patterns causing certain trends in interpersonal relationships and leading individuals to
behave in line with expectations about how others will react to their wishes (Safran &
Muran, 2000).In line with its constructivist origins (Neimeyer & Mahoney,1995),
MIT also creates a model of
(c) each single case using the construct system that underlies subjective experience and assists in ascribing meaning to relationships, and
(d)the way in which thought processes are organized.If a patient displays a co-
occurrence, a therapist tries to understand the hierarchical relationship between the
disorders and their influences on each other's functioning processes.
In this article, we review the central premises of MIT in treating comorbid
personality disorders and then present a clinicalil lustration of its uses and typical
outcomes.
次に長い説明
Metacognitive Interpersonal Therapy
According to MIT, patients with a PD have difficulty thinking about thinking
(see also Bateman and Fonagy,this issue,181-194). For instance,it can be
problematic for them to recognize their own thoughts and feelings or examine the
accuracy of something they hold to be true. They can find it impossible to divine
others' feelings or recognize the requirements of a social situation. Moreover,they
can find it difficult to grasp that self is not always at the heart of others' thoughts.
Metacognitive system dysfunctions can explain a variety of pathological forms
(Dimaggio et al., 2007): For example,limited access to own affects appears to be a
pathogenetic mechanism common to disorders such as obsessive-compulsive,
avoidant, narcissistic, and dependent. Deficits in metacognition may obstruct
courses of action driven by emotions in all of them; affects are a fundamental
decision-making tool and, without awareness of one's affects, actions are less prompt
and spontaneous and there can be serious indecisiveness (Damasio,1994).
Metacognitive interpersonal therapy for PDs rests on several assumptions.
First,
interpersonal relationships among patients suffering with personality disorders are
dysfunctional and, consequently, patients find it hard to build up a good alliance
with their therapist.
Second,there are specific interpersonal cycles in line with the
diagnosis of PD. Very early in treatment, clinicians can foresee the major alliance
rupture patterns and take action to reduce theirimpact and the risk of early
dropouts.
Third, metacognition among patients with a personality disorderis
probably impaired. Patients thus find it difficult to carry out several operations
which,in classical forms of treatment,including standard cognitive-behavioral
therapy, are taken for granted:identifying their thoughts and emotions oftheir own
accord or as the result of specific questions from their therapist, understanding
other's intentions, and developing a collaborative relationship with a problem-
solving attitude. Clinicians who practice MIT tackle the impaired aspects of patients'
metacognition and improving those specific aspects of self-reflection or under-
standing other's mind in which they fail.
To interrupt patients' self-perpetuating pathological circuits,therapists who
practice MIT first need to attune with them and make the relationship as little
disturbed as possible. To do so,it is important to avoid allowing themselves to get
involved in or contributing actively to the perpetuation of any interpersonal cycles,
and to encourage,instead, a discourse based on the themes with which patients find
themselves most at ease. Once such a position is reached,therapists can work at
improving metacognition.
Psychothrapists can look in each session to build a strong therapeutic relation-
ship---in which it is possible to discuss states of mind--to interrupt patients' self-
perpetuating cycles and to help them to enrich their inner and relational lives.
Another MIT focus is constructing new and more adaptive forms of experience.
Patients with one or several PDs have difficulty switching into pleasant states,
feeling,for example,immediately guilty each time they relax. Metacognitive
interpersonal therapy attempts to facilitate identification of warded-off or
unrecognized states of mind (Horowitz,1987) and their integration into patients'
daily social action. For example,in the case of a narcissistic patient with borderline
and paranoid characteristics, a therapist encouraged the emergence of previously
unidentified fragile parts seeking help (Nicolo, Carcione, Semerari, & Dimaggio,
2007).
Metacognitive interpersonal therapy operates within multiple modalities,for
example,the individual plus group format. Through peer feedback, group therapy
helps in perceiving aspects of experience. Other group members may,for example,
observe that a patient portrays herself or himself as inept,incapable, and clumsy, but
is able to express herself or himself well, with sensible and useful comments. A
therapist can reinforce this feedback and integrate this new self-aspect into the
patient's self-image during individual therapy. Role-playing in groups can improve
metacognition.In fact, patients receive feedback on their posture and body signals
and the extent to which they differ from their self-descriptions. The patient we
mentioned,for example, described himself as clumsy and awkward. During role-
playing, another group member chose him as a salsa teacher and he confessed that he
really had taught this dance. The idea of being skilled at dancing was not integrated
into his self-image and had not surfaced during individualtherapy.
According to MIT, patients with a PD have difficulty thinking about thinking
(see also Bateman and Fonagy,this issue,181-194). For instance,it can be
problematic for them to recognize their own thoughts and feelings or examine the
accuracy of something they hold to be true.
というのは説得的ではないですね
薄いトイレットペーパー
悩みそのものと悩みの構造=精神の立体視
Change Processes in Residential Cognitive and Interpersonal Psychotherapy for Social Phobia: A Process-Outcome Study
SOCIAL PHOBIA is a prevalent, severe,impairing, and
chronic disorderfor which effective treatment
methods are clearly needed. Based on an empirical
analysis of the cognitive processes in social phobia,
Clark and Wells (1995) developed a new cognitive
model.Individual cognitive therapy (CT) derived
from this model has been associated with large effect
sizes and superior to a combination of fluoxetine and
self-exposure (Clark et al., 2003),to a combination
of exposure and applied relaxation (Clark et al.,
2006),to group CT (Mortberg, Clark, Sundin, &
Aberg Wistedt, 2007; Stangier, Heidenreich, Peitz,
Lauterbach, & Clark, 2003), and to routine
psychiatric treatment involving medication and
emotional support(Mortberg et al., 2007). On the
other hand, symptoms of social phobia may be
viewed as a part of and/or as maintained by more
general interpersonal difficulties. Thus,interpersonal
psychotherapy (IPT) may also be considered a
plausible treatment for social phobia (Lipsitz,
Markowitz, & Cherry,1997).IPT has proved to
be efficacious for a number of disorders (Weissman,
Markowitz, & Klerman, 2000). A clinical case series
indicated that patients with social phobia improved
during individual IPT (Lipsitz, Markowitz, Cherry,
& Fyer,1999), but superiority to a control condition
has yet to be demonstrated. Although both these
therapies may prove to be efficacious, efficacy in
itself does not prove the validity of a therapy model.
An analysis of in-therapy change processes may both
serve to evaluate the adequacy of the applied model
and to suggest improvement in the therapies.
日本人肥満化対策案
沸騰する東京
ディズニーvs第三セクター
いろいろなOSがあります
精神療法における特異的要因と非特異的要因
DIT ;Dynamic Interpersonal Therapy
Effectiveness,relapse prevention and mechanisms of change of cognitive therapy vs. interpersonal therapy for depression: study protocol for a randomised controlled trial
Effectiveness,relapse prevention and mechanisms of change of cognitive therapy vs. interpersonal therapy for depression: study protocol for a randomised controlled trial
認知療法を受けた人と対人関係療法を受けた人、さらにはウェイティングリストの人の三群について
比較検討している。
デパケンが片頭痛の発作予防の適応を取得
適応を取得したのは、同社が製造販売する「デパケン錠100、同錠200」「デパケン細粒20％、同細粒40％」「デパケンR錠100、同R錠200」「デパケンシロップ5％」。いずれもバルプロ酸ナトリウムとして400～800mgを1日2～3回に分けて経口投与し、1日量は1000mgを超えないこととしている。
日本頭痛学会などが2005年にまとめた「慢性頭痛診療ガイドライン」では、バルプロ酸をアミトリプチリン、プロプラノロール、チモロールと並んで最も効果の期待できる「Group1（有効）」に位置付けていた。このため国内では、適応外処方されるケースが少なくなかった。
バルプロ酸ナトリウムによる片頭痛の発作抑制については、厚生労働省の「医療上の必要性の高い未承認薬・適応外薬検討会議」で議論され、同社は昨年11月、薬事・食品衛生審議会の事前評価を経た後に公知申請していた。公知申請とは、医薬品の有効性や安全性が医学薬学上公知であるとして、医薬品の効能・効果の追加に当たっての臨床試験の一部あるいは全てが免除される制度。
慢性頭痛の診療ガイドラインでは、トリプタンやエルゴタミンの投与といった急性期治療だけでは十分な効果が得られず、片頭痛発作により日常生活に支障がある場合や、急性期治療薬が使用できない場合などは、予防療法を行うよう勧めている。また、片頭痛発作が月に2回以上あるケースでは、予防療法の実施の検討を推奨する。予防療法は、有害事象がない限り、十分な臨床効果が得られる用量とし、2～3カ月ほどの期間をかけて効果を判定するとしている。
residential counselor
・Residential counselors teach life skills to adults with mental illness in a group home. : 居住するカウンセラーはグループホームに住む精神病の大人に生活技能を教えます。
納豆が体にいい
循環論法
たいていは過剰診断になってしまう
