Transcript Psychopath-treatment

Disorders
Who Gets What?
Defining Abnormality
Medical approach
 Statistical approach
 Functional approach

These reflect two basic views of disorders
--brain based
--behavior/experience/situation based
The “two worlds” of psychiatry
DSM-IV
Axis 1: Syndromes (Scz, Depress, etc.)
 Axis 2: Retardation & Personality Disorders
 Axis 3: General Medical Condition
 Axis 4: Social/Environmental Problems
 Axis 5: Global Assessment & Coping
 Older classification (primarily of Axis 1 & 2)
dichotomized: Neuroses & Psychoses
 Mood (Dep. Bipolar) vs. Thought (Scz) Disrdr
 Now replaced by highly elaborated DSM-V
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Prevalence of Neurotic Disorders by Age
Prevalence of Neurosis by Age & Social Class
Prevalence of Psychosis by Age & Gender
Heritability of Psychosis: Schizophrenia
Scz incidence & poverty/residential area
Some Interim Conclusions
Psychoses (focus on SCZ) is a disorder of
heredity and/or prenatal environment
 But it’s also a disorder of poverty (and that may
be bidirectional)!
 Another view of prevalence and recent dramatic
changes in prevalence
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Prevalence of Major Disorders
Schizophrenia: approx. 1%
 Bipolar Disorder: approx. 1%
 Depression:
approx. M 13% F 21%
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Treatment
Overview
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Brief History
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Psychological Treatments
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Biomedical Treatments
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Client-Therapist Relationship
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Is Treatment Effective?
History
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Earliest history
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Mental illness believed to be caused by evil
spirits
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Treatments were harsh, ineffective
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Drill holes in skulls to create exits for spirits
Make the body horribly uncomfortable for the spirits
Purge demons through inducing vomiting
History
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Middle Ages
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Mental illness viewed more like a disease
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Mental institutions were created
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Purpose: confine madmen
Included other social “undesirables”
Inhumane treatment (shackles and chains)
Beginning of Reform
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Early to Mid 1800s
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Philippe Pinel put in charge of Paris’ hospital
system
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Removed shackles and chains
Patients allowed to exercise, venture outside
Beginning of Reform
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Dorthea Dix
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Fought for humane
treatment of patients in
U.S.
19th century
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Freud’s “talking cure”
Psychological Treatment
Overview
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Treatment involves addressing three
major components of the illness:
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Biological
Psychological
Social
Something to keep in mind:
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These three major components are not
necessarily black-and-white or either-or
Who provides treatment?
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Clinical psychologists
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Psychologists
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Neurologists
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Psychiatric Nurses
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Marriage and Family Counselors
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Social workers
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School counselors
Who seeks treatment?
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People with mental illness, hoping to relieve
pain and dysfunction
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People with subsyndromal disorders
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People looking for assistance in recovering
from grief, anxiety, confusion, relationship
issues…
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Women
European Americans
Financially well off
Psychological Treatments
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Focused on changing the way the patient thinks
and behaves
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Involves discussion, instruction, or training
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Over 500 different forms of such treatment
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Psychodynamic
Humanistic
Behavioral
Cognitive
Psychodynamic Approaches
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Illness result of unconscious conflicts developed early in
childhood
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Defense mechanisms shield from the inner conflict
 This can lead to symptoms of mental illness
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Treatment: Uncovering unconscious desires and
conflicts, and resolving them
 Integrate thoughts and memories coherently
Psychodynamic Approaches
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“Working through” the conflict
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Transference
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Used as a therapeutic tool
In order to be effective, therapist must remain
neutral
Humanistic Approaches
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Based off of Freud’s “talking cure”
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However, less focused on basic drives
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Instead, focus on creating meaning
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Clients need to take responsibility for their lives
and actions, and live in the “here and now”
Humanistic Approaches
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Client-Centered Therapy (Carl Rogers)
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Focuses on achieving self-acceptance
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Does not pass judgment, or provide instruction
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Aim is to create an environment in which the client feels
understood and valued
Humanistic Approach
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Creating the therapeutic environment
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Genuineness- sharing authentic reactions
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Unconditional positive regard
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Non-judgmental, accepting
Empathic Understanding- putting oneself in the
patients’ shoes
Behavioral Approaches
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Reaction to Freud’s psychoanalysis
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Viewed Freud’s approach as too unscientific
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Treatment directed at reducing or eliminating
problematic behaviors
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Approach involves replacing old habits with more
effective or adaptive behaviors
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Classical conditioning, operant conditioning, modeling
Behavioral Approaches
Classical Conditioning Techniques
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Treatment of Phobias
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Extinguish the association between the neutral
stimulus and the fearful stimulus
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Exposure Therapy
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Train clients in deep muscle relaxation, pair
relaxation with the fearful stimulus
Create a hierarchy of progressively more frightening
stimuli
Systematic desensitization: gradual exposure to the
real phobic stimulus
Systematic Desensitization
Behavioral Approaches
Operant Conditioning Techniques
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Token economies
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Earn tokens for positive behaviors, which can be exchanged
for prizes
Shaping
Contingency Management
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Strict consequences for certain behaviors
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Successful for shaping communicative behavior in children
with autism
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Modeling Techniques
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Therapist perceived as role model
Cognitive-Behavioral Approaches
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Rational Emotive Behavioral Therapy
(Albert Ellis)
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People typically think that an event
causes them to behave a certain way
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But…beliefs matter
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A (acting event) B (belief)  C
(consequence)
Focused therapy on changing beliefs
Teacher-like
Cognitive Therapy
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Aaron Beck
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Focused on changing dysfunctional
thought
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Cognitive Restructuring
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Challenge a person’s unhealthy
beliefs or interpretations
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Used persuasion and confrontation
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Brief, problem-focused
Initially treated depression
Cognitive-Behavioral Therapy
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Followers of Ellis and Beck blended the
two therapies to form CBT
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Focus on addressing problems the patient
wishes to solve
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Often clients are assigned homework
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Practice new ways skills or thought techniques
Eclecticism
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Modern therapy tends
to blend aspects from
many of these
perspectives
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Makes sense, since
there are often many
causes of mental
illness
Client-Therapist Relationship
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Therapeutic Alliance
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Support
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Trust
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Hope
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Understanding
Group Therapies
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Often groups are chosen
because they share similar
problems (e.g., Alcoholics
Anonymous)
Focus on the shared
problems, less on the
individuals’ emotions
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Advantages
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Social support
Share advice, information
Observe other peoples’
successes
Realize that not alone, others
share similar problems
Couple and Family Therapy
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Views the family or relationship as a
complex system
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One person’s negative behavior or cognitions
may reflect a larger issue for the entire family
or relationship
Biomedical Treatments
The Early Gruesome Years
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Trephination
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Allowed “evil spirits” to escape the skull
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Hot or Cold Baths
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Spinning
Biomedical Treatments
Psychosurgery
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Prefrontal Lobotomy
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Sever connections between
thalamus and frontal lobes
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Disrupted higher cognitive
functions
Modern techniques are more
precise and used as a last
resort treatment
Electroconvulsive Therapy (ECT)
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Brief electrical current
passed through the brain
causing a convulsive seizure
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Originally developed to treat
schizophrenia
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Very effective for treating
severe depression (70-90%
effective)
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Memory impairment
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Mechanisms are not known
Different Therapies for Different
Conditions
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Medical: Brain targeted drug interventions
examples:
--SCZ: Dopamine receptor blockers (the
better the block the more effective it is)
--Other neurotransmitters involved as well
--Depression: ex. Norepinephrine uptake or
release+, Serotonin release+, & a host of
other neurotransmitter controls involved
-- Electro-convulsive shock therapy!
Pharmacological Treatments
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Psychotropic drugs
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Not only helped treat patients, but also further
understanding of the illness
Pharmacological Treatments
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Antipsychotics
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Treat positive symptoms of schizophrenia
Not effective for treating the negative symptoms
Most common are Thorazine, Haldol and Stelazine
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Block dopamine receptors in particular brain pathways
Atypical Antipsychotics
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Treat negative symptoms of schizophrenia, too
Risperdal, Clozaril, Seroquel
Antipsychotics and
Deinstitutionalization
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Movement in the 1950s shortly after
development of the first antipsychotics
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Pros
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Aimed to provide less expensive mental health care at
local community centers instead of institutions
Fewer people spending their lives in institutions
Shorter stays
Downside
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Lack of appropriate care in community settings
Lack of integration into the community (support
services, employment)
Many mentally ill are now homeless, or in jail
Deinstitutionalization
Antidepressants
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Monoamine Oxidase Inhibitors (MAOIs)
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Nardil
Tricyclic antidepressants
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Tofranil
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Increase serotonin and norephinephrine for
synaptic transmission
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Both very effective (significant improvement in
65% of patients)
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Many negative side effects
Antidepressants
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Selective Serotonin Reuptake Inhibitors (SSRIs)
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Prozac, Zoloft, Paxil, Celexa, Lexapro
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Minimally effect dopamine and norepinephrine, and
maximally effect serotonin
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Reduced side effects
Most commonly prescribed
Atypical Antidepressants
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Effect serotonin, norepinephrine and dopamine in
various ways
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Wellbutrin (fewer side effects)
Antidepressants
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Downside
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Takes a while before effective (a month)
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Trial-and-error
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Side effects
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Weight gain, nausea, diarrhea, insomnia, reduced
sexual desire or response
Mood Stabilizers
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Treat symptoms of bipolar disorder
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Lithium carbonate
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Treats manic episodes as well as depressive episodes
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Side Effects
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Weight gain, sedation, dry mouth, tremors
Adherence to medication
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Often patients do not wish to treat mania, only depression
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Lethal at high doses
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Effective for 60 – 70% of patients
Anxiolytic Medications
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Treat anxiety disorders
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Increase neurotransmission of GABA
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Beta Blockers
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Benzodiazepines
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Tricyclic Antidepressants and SSRIs
Anxiolytic Medications
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Beta Blockers
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Controls autonomic arousal
Benzodiazepines
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Valium, Xanax, Klonopin
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Short term treatments
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Highly addictive
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Interact dangerously with alcohol
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New drugs are being developed to reduce these negative side
effects
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Rebound effect
Medication: Costs and Benefits
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Can be highly effective
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Only treats and controls the
symptoms
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Relapse
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Requires trial-and-error for
correct drug and correct dosage
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Side effects
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Reduce adherence to medication
Overprescription
Emerging Biomedical Treatments
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Repetitive TMS
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Areas of the brain stimulated
with magnetic coil for 20-30
minutes over several weeks
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Effective for medicationresistant depression
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No cognitive side effects
Deep Brain Stimulation
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Electrodes implanted in brain
Combined Treatments
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Most therapists use a combination of
treatments
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Drug treatments for short-term effects
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Therapy for long-term effects
Evaluating the Efficacy of Treatments
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Randomized Clinical Trial (RCT)
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Treatment group
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Placebo group
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Random assignment
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Symptoms and severity similar across
participants
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Follow participants over several months
Efficacy vs. Utility
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Difficult to run RCT for psychotherapy
 Waitlist
 Manualized Therapy
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Controlled studies allow researchers to come to
conclusions about the efficacy of particular
treatments
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In many circumstances, patients have more than
one illness
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Also, therapists typically use more than one
approach
Is therapy effective?
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A meta-analysis found that 80% of
patients who received treatment fared
better than those without
Are all Therapies Equally Effective?
Who provides the most effective psychological
treatment?
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Number of years of practice?
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Professional credentials?
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Not necessarily
No
The rapport between therapist and client
seems to be strongest predictor
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Respect, trust, comfort
Who is most likely to benefit from
treatment?
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Strong alliance with therapist
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Shop around!
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Motivated
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Optimistic
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More effective with more therapy
Are All Treatments Equally Effective?
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A depression meta-analysis shows…
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Drug treatment alone 55% effective
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Therapy alone 52% effective
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Drug AND therapy 85% effective!
(New England Journal of Medicine, 2000)
Are all Treatments Equally Effective?
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Treatment more effective than no
treatment
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Combining treatments appears most
beneficial
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Some therapies seem particularly effective
for specific disorders
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Exposure therapy phobias
Moral of the Story
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Treatment is effective!
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Modern treatments are much more
effective and humane than past
treatments
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The relationship between therapist and
client really matters!
Recent Reconceptualization
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Some people are able to cognitively
overcome even serious levels of disorders
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Available to psychotherapy
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Find meaning in some symptoms
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Able to live normally or quasi-normally
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Example in Nash film
If you feel you need help…
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Seek it! Ask for advice, or set up an appointment
with a counselor. It’s not a weakness.
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Make sure the therapist is a good match for you!
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Remember it can take time and you may face
some setbacks, but also…
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Remember treatment is effective! Most people
improve!