Transcript 023_2004_Treatment1_web

Three Minute Review
SCHIZOPHRENIA
• 1% incidence but big implications
– can be devastating, 1/3 chronic, begins early in life, factor in
homelessness
• Causes
– strong genetic contribution; environmental factors also contribute
• placental environment, family environment
– positive symptoms may be related to dopamine excess or imbalance
– negative symptoms may be related to brain damage
• bigger ventricles indicate brain atrophy
– viral infection hypothesis
• seasonality effect
• exposure to viruses during second trimester of pregnancy may affect
neural organization
– hippocampal neurons much less organized in schizophrenics
PERSONALITY DISORDERS
• DSM Axis II, controversial
• 3 clusters
– dramatic/impulsive
– anxious/fearful
– odd/eccentric
• Antisocial Personality Disorder ~= Criminality ≠ Psychopathy
= Sociopathy
• Psychopaths
– have greatly reduced emotional reactions
– do not learn from punishment (but can learn from positive
reinforcement)
Test Yourself
•
A.
B.
C.
D.
E.
Which part of the brain is often enlarged in
schizophrenics?
amygdala
hippocampus
basal ganglia
orbitofrontal cortex
ventricles
Psychological Treatments Through History
• demonic possession
– e.g., trephination(12th century, though still seen in
preliterate tribes in 20th century)
• disease model
– “hospitalization”, bedlam tours
– Phillippe Pinel suggested releasing inmates in the French
revolution
• psychoanalysis
• behaviorism
Pinel
Two Major Approaches
BIOLOGICAL TREATMENTS
• “It’s your neurotransmitters/brain.”
– Psychopharmacology
– Electroshock Therapy
– Psychosurgery
PSYCHOLOGICAL TREATMENTS
• “It’s your life/behavior/reaction.”
– Psychotherapy
•
•
•
•
•
Psychoanalysis
Humanistic Therapy
Cognitive Therapy
Behaviour Therapy
Other
Psychopharmacology: Antipsychotics
Antipsychotics
• mainly dopamine-based
• undesirable side effects
• may not help negative symptoms of
schizophrenia
• side effects
– tardive dyskinesia
DEINSTITUTIONALIZATION
•
•
patients often fight meds or go off
them
newer generation antipsychotics
(clozapine)
–
–
–
–
affects dopamine plus other NTs
may help negative symptoms
no motor side effects
risk of serious blood disorder
Psychopharmacology: Anti-anxiety
• tranquilizers, barbiturates
• drugs like Valium
–  GABA, an inhibitory
neurotransmitter
• Valium reduces excitability of
neurons
– useful for generalized anxiety
– doesn’t seem to help phobias,
OCD or panic disorder
• danger of overdose, suicide
• addictive
Psychopharmacology: Antidepressants
• monoamine hypothesis
– depression results from reduced monoamines (esp. serotonin &
norepinephrine)
• traditional antidepressants
– tricyclic antidepressants
• block reuptake of serotonin and norepinephrine
– monoamine oxidase (MAO) inhibitors
• increase NE and serotonin
– many side effects
– use has declined since SSRIs although they may still be valuable in severe
cases
• second generation antidepressants
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–
–
–
SSRIs (selective serotonin reuptake inhibitors)
e.g., Prozac, Paxil, Zoloft. etc.
originally for depression, now marketed for OCD, social phobia
most frequently prescribed psychoactive drugs in US
• lithium
– can be useful in stabilizing manic depression
– no idea how/why it works
Miracle drug or personality pill?
Problems with the Monoamine Hypothesis
• Why is it that SSRIs affect serotonin levels almost
immediately but don’t have much of an effect on
depression for several weeks?
• Why do drugs that work on serotonin and
norepinephrine -- two very different brain systems -have similar effects?
Depression and Sleep
• sleep disrupted in depressed
people
– too much REM
• short REM latency
• lots of REM periods
– too little slow-wave sleep
• in cats, twenty different
antidepressant drugs all reduced
REM and increased slow-wave
sleep
• first-degree relatives of
depressives without depression
symptoms themselves show
reduced REM latency
• those with the strongest effects
are most likely to become
depressed
• sleep deprivation or REM
deprivation may reduce
depression
• perhaps sleep also plays a role in
SAD
SAD: Phototherapy
• bright lights
– help SCN reset
circadian rhythms?
– helps SAD and “winter
blahs”
• Do you need the high
electricity bills?
– A one-hour walk
outside each morning
reduces SAD
symptoms
Electroconvulsive Therapy (ECT)
• last resort for severe
depression but it often works
– 70% success when everything
else has failed
• has become more humane
over years
Jack Nicholson as McMurphy in
One Flew Over the Cuckoo’s Nest
undergoes ECT and ultimately a
lobotomy
– anesthesia
– muscle relaxants
– unilateral stimulation to reduce
retrograde memory loss
• why does it work?
– ???
Transcranial Magnetic Stimulation (TMS)
• magnetic fields induced by Figure-8 coil
creates an electrical current in a focal part
of the brain
• new technique in cognitive neuroscience
– zap an area, disrupt a function
– “temporary lesion”
• may hold promise for alleviating
depression
– especially TMS to left frontal lobe
Psychosurgery
• 12th c. trephination
• 1950s heyday of lobotomies
• modern day cingulotomy
– very focal surgery to cingulate cortex
– can be useful in severe OCD or depression
– absolute last resort
trephinated skull
McLobotomy
cingulotomy
Psychotherapy
• Most modern day
therapists use an
eclectic approach -- a
bit of everything
Psychodynamic Therapy
ASSUMPTIONS
• Behavior is driven by biological urges,
interpsychic conflict and developmental
fixations
GOALS
• client seeks insight regarding
unconscious conflicts and motivations
METHODS
• free association, dream interpretation,
talking cure, catharsis
• transference: patient’s unconscious
feelings about person in their life
experienced as feelings toward therapist
• therapist extracts hidden motivations
Humanistic Therapy
ASSUMPTIONS
• People are good and have innate worth
GOALS
• to promote personal growth and selfactualization
• to help clients become aware of their own
feelings and wishes and to gain control of
their lives
METHODS
• client-centred: therapist is a sounding
board for clients thoughts
• reflection: therapist repeats client’s
concerns in order to help client clarify
feelings
• empathy: therapist takes client’s
perspective
• unconditional positive regard: safe, nonjudgmental atmosphere in which client is
worthy and capable
Humanistic Sample
• Client: I get so frustrated at my parents. They just
don’t understand how I feel. They don’t know what
it’s like to be me.
• Therapist: You seem to be saying that the things
that are important to you aren’t very important to
your parents. You’d like them now and then to see
things from your perspective.
Cognitive Therapy
ASSUMPTIONS
• Behavior is controlled by habitual ways of thinking
GOALS
• to replace maladaptive ways of thinking with adaptive ways of thinking
about events related to self
METHODS
• problem-centred: focused on client’s specific problems
• thought stopping, recording automatic thoughts, refuting negative
thinking, reattribution, homework assignments
• Rational Emotive Therapy (Ellis)
• Beck’s Cognitive Therapy: counteract negative thoughts about self and
world
Rational-Emotive Therapy
Albert Ellis
Examples of irrational beliefs
• “Everyone must like me”
• “I must be perfect”
• “It’s horrible when things aren’t the way I expect”
• “It’s easier to deny problems than face them”
• “I have no control over what happens to me”
Change an irrational belief to
change the negative
emotional reaction to an event
RET Sample
• Client: Life isn’t fair. I shouldn’t have been fired under those
circumstances.
• Therapist: What circumstances are you referring to?
• Client: Being fired right after my dad died.
• Therapist: That your father died is unrelated to the fact that you were
fired from your job.
• Client: It’s still unfair.
• Therapist: That has nothing to do with fairness. These two events are
related only in your mind, and putting them together is irrational. What
happened is unfortunate, but there is no conspiracy here.
Behavior Therapy
ASSUMPTIONS
• Maladaptive behaviors are acquired through learning
GOALS
• to replace maladaptive ways of thinking with adaptive ways of coping
METHODS
• behavior modification
– based on operant conditioning
– reward desired behaviors and punish unwanted behavior
– example: token economies
• habituation
– exposure treatment: client repeatedly exposed to threatening stimulus
– systematic desensitization: gradual exposure treatment
– flooding: abrupt exposure
• modelling: client models therapist’s actions
• aversive conditioning (e.g., Antabuse)
Cognitive Behavioral Therapy
• uses both cognitive and behavioral approaches
• correct faulty behaviors and faulty cognitions
• example: social phobia
– train social skills
– understand how cognitive appraisals of others’ reactions
may be inaccurate
• quite effective for anxiety and mood disorders
Systematic Desensitization
Other therapies
Life Coaching
• new trend or California
flakiness?
Group Therapy
• cheaper than individual
therapy
• clients can find support in
others with same problem
• may not need formallytrained leader (e.g., AA)
Marital and Family
Counselling
• work on interactions
How effective is therapy?
• people tend to improve
regardless
– people often seek help at worst
times
– 75% of neurotic patients
improve regardless of therapy
• any treatment is better than no
treatment
• not that much difference among
various psychotherapy types
• a caring therapist is essential
• confession is good for the spirit
– some support for idea of
catharsis
– people talking about problems
improves health and cognition
• non-specific effects
– support of therapist
– hope for improvement
Different problems, different solutions
Different problems, different solutions
ANXIETY DISORDERS
• anxiety
– cognitive-behavioral therapy
• specific phobias
– cognitive-behavioral therapy
• social phobias
– behavioral therapy
– SSRIs may help
• panic disorder
– drugs help symptoms but not anticipatory anxiety
– cognitive therapy helps reduce anxiety
• obsessive-compulsive disorder
– SSRIs and related drugs
– cognitive-behavioral therapy
– conditioning
Different problems, different solutions
MOOD DISORDERS
• depression
– cognitive-behavioral therapy
– therapy + drugs > either alone
– moderate: SSRIs
• 60-70% of patients relieved (vs. 30% for placebos) and less likely to
relapse (20% vs. 80%)
• can require trial-and-error approach
– severe: MAOIs, tricyclics, ECT/TMS
• seasonal affective disorder
– phototherapy
• bipolar disorder
– lithium helps mania in ~3/4 of patients
• unpleasant side effects
– psychotherapy helps keep patients on meds
Different problems, different solutions
PERSONALITY DISORDERS
• psychotherapy can help some disorders (e.g., borderline)
• antisocial personality disorder
– drugs can reduce aggression
– therapy useless, possibly worse than nothing
– prevention may be help
• identify kids with conduct disorder
SCHIZOPHRENIA
– antipsychotics
– social skills training
– training in cognitive skills (e.g., coping with voices) has not been
especially successful
Prevention is the best medicine
• psychologists coming to
realize that prevention can
be better than cure
• many disorders such as
depression have a high
relapse rate; if you can
avoid the first episode,
perhaps you can avoid a
lifetime of trouble
• may be most cost-effective
to identify individuals with
a diathesis and help them
avoid a stress that will
invoke a disorder