Transcript Comer, Abnormal Psychology, 8th edition

Chapter 15
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Treatments for Schizophrenia and
Other Severe Mental Disorders
• For much of human history, people with
schizophrenia and other severe mental
disorders were considered beyond help
• Though schizophrenia is still extremely difficult
to treat, the discovery of antipsychotic drugs has
enabled people with the disorder to think clearly
and profit from psychotherapies
• Each of the models offers treatments for
schizophrenia, and all have been influential at
one time or another
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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How Is Schizophrenia Treated?
• For more than half of the 20th century, people
with schizophrenia were institutionalized in
public mental hospitals
• Because patients failed to respond to traditional
therapies, the primary goals of the hospitals
were to restrain them and give them food,
shelter, and clothing
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Institutional Care in the Past
• The move toward institutionalization began in
1793 with the practice of “moral treatment”
• Hospitals were located in isolated areas to
protect patients from the stresses of daily life
and to offer them a healthful psychological
environment
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Institutional Care in the Past
Institutional Care in the Past
– Unfortunately, problems with overcrowding,
understaffing, and poor patient outcomes led to loss
of individual care and the creation of “back wards” –
human warehouses filled with hopelessness
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• States throughout the U.S. were required by law
to establish public mental institutions (state
hospitals) for patients who could not afford
private care
Institutional Care in the Past
– The most common pattern of decline was called the
social breakdown syndrome, which involved:
• Extreme withdrawal, anger, and physical aggressiveness
• Loss of interest in personal appearance and functioning
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• Many patients not only failed to improve under
these conditions but developed additional
symptoms, apparently as a result of the
institutionalization itself
Institutional Care Takes a Turn for the Better
• In the 1950s, clinicians developed two
institutional approaches that brought some hope
to chronic patients:
– ________ therapy
– _______ economies
• Based on behavioral principles
• These approaches particularly helped improve
the personal care and self-image of patients,
problem areas that were worsened by
institutionalization
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• Based on humanistic principles
Institutional Care Takes a Turn for the Better
• The premise is that institutions can help patients
make clinical progress by creating a social climate
(“milieu”) that promotes productive activity, selfrespect, and individual responsibility
• Milieu-style programs have been set up in
institutions throughout the Western world with
moderate success
• Research has shown that patients with
schizophrenia in milieu programs often leave the
hospital at higher rates than patients receiving
custodial care
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Milieu therapy
Institutional Care Takes a Turn for the Better
• Based on operant conditioning principles, token economies
are used in institutions to change the behavior of patients with
schizophrenia
• Patients are rewarded when they behave in socially
acceptable ways and are not rewarded when they behave
unacceptably
• Immediate rewards are tokens that can later be exchanged
for food, cigarettes, privileges, and other desirable objects
• Acceptable behaviors likely to be targeted include care for
oneself and one's possessions, going to a work program,
speaking normally, following ward rules, and showing selfcontrol
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The token economy
Institutional Care Takes a Turn for the Better
• Researchers have found that token economies help
reduce psychotic and related behavior
• However, questions have been raised about such
programs:
• Many research studies have been uncontrolled;
instead of patients being randomly assigned to
groups, a whole ward will participate in the
program
• Are such programs ethical and legal? Aren't all
humans entitled to basic rights, some of which are
compromised in a strict token economy system?
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The token economy
Institutional Care Takes a Turn for the Better
• Questions have been raised about such
programs:
• Are such programs truly effective? For
example, patients may change overt
behaviors but not underlying psychotic
beliefs
• Transitioning from a token economy
system to community living may be difficult
for patients
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The token economy
Institutional Care Takes a Turn for the Better
– They are still used in many mental hospitals, usually
along with medication
– This approach has also been applied to other clinical
problems
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• Milieu therapy and token economies have
helped improve the personal care and selfimage of patients, problem areas worsened by
institutionalization
Antipsychotic Drugs
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• While milieu therapy and token economies
helped improve treatment outcomes, it was the
discovery of antipsychotic drugs in the 1950s
that revolutionized treatment for those suffering
from schizophrenia
Abnormal Psychology | Ronald J. Comer | Ninth Edition
• The discovery of antipsychotic medications dates
back to the 1940s, when researchers developed
antihistamine drugs for allergies
• It was discovered that one group of antihistamines,
phenothiazines, could be used to calm patients
about to undergo surgery
– Psychiatrists tested one of the drugs, chlorpromazine, on 6
patients with psychosis and observed a sharp reduction in
their symptoms
– In 1954, chlorpromazine (under the trade name Thorazine)
was approved for sale in the U.S. as an antipsychotic drug
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Antipsychotic Drugs
Antipsychotic Drugs
– Those developed throughout the 1960s, 1970s, and
1980s are now referred to as “conventional”
antipsychotic drugs
• These drugs are also known as neuroleptic drugs, because
they often produce undesired movement effects similar to
symptoms of neurological diseases
– Drugs developed in recent years are known as
“atypical” or “second-generation” antipsychotics
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• Since the discovery of the phenothiazines, other
kinds of antipsychotic drugs have been
developed
How Effective Are Antipsychotic Drugs?
• Research has shown that antipsychotic drugs
reduce schizophrenia symptoms in at least 65%
of patients
• In most cases, the drugs produce the maximum
level of improvement within the first six months
of treatment
– Symptoms may return if patients stop taking the drugs
too soon
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– In direct comparisons, drugs appear to be more
effective than any other approach used alone
How Effective Are Antipsychotic Drugs?
– Correspondingly, people who display largely positive
symptoms generally have better rates of recovery
than those with primarily negative symptoms
• Although the use of such drugs is now widely
accepted, patients often dislike the powerful
effects of the drugs, and some refuse to take
them
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• Antipsychotic drugs, particularly the conventional
ones, reduce the positive symptoms of
schizophrenia more completely, or at least more
quickly, than the negative symptoms
The Unwanted Effects of Conventional
Antipsychotic Drugs
– These are called “extrapyramidal effects” because
they appear to be caused by the drugs' impact on the
extrapyramidal areas of the brain
– These effects are so common that they are listed as a
separate category of disorders – medication-induced
movement disorders – in the DSM-IV-TR
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• In addition to reducing psychotic symptoms,
conventional antipsychotic drugs sometimes
produce disturbing movement problems
The Unwanted Effects of Conventional
Antipsychotic Drugs
– Muscle tremor and rigidity
– Bizarre movements of the face, neck, tongue, and
back
– Great restlessness, agitation, and discomfort in the
limbs
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• The most common of these effects produce
Parkinsonian symptoms, reactions that closely
resemble features of the neurological disorder
Parkinson's disease, including:
• The Parkinsonian and related symptoms seem
to be the result of medication-induced reductions
of dopamine activity in the basal ganglia and
substantia nigra, parts of the brain that
coordinate movement and posture
• In most cases, the symptoms can be reversed if
an anti-Parkinsonian drug is taken along with the
antipsychotic
– Sometimes the dosage must be decreased or the
medication must be halted altogether
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The Unwanted Effects of Conventional
Antipsychotic Drugs
The Unwanted Effects of Conventional
Antipsychotic Drugs
– Symptoms include muscle rigidity, fever, altered
consciousness, and improper functioning of the autonomic
nervous system
• As soon as the syndrome is recognized, drug use is
discontinued and each symptom is treated medically
– Individuals may also be given dopamine-enhancing drugs
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• In as many as 1% of patients, particularly elderly
ones, conventional antipsychotic drugs produce
neuroleptic malignant syndrome – a severe,
potentially fatal reaction
Unwanted Effects of Conventional
Antipsychotic Drugs
– This reaction, called tardive dyskinesia, involves
writhing or tic-like involuntary movements, usually of
the mouth, lips, tongue, legs, or body
• It affects more than 10% of those taking the drugs
• Tardive dyskinesia can be difficult, sometimes impossible, to
eliminate
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• A more difficult side effect of conventional
antipsychotic drugs appears up to 1 year after
starting the medication
Unwanted Effects of Conventional
Antipsychotic Drugs
– They try to prescribe the lowest effective dose
– They gradually reduce or stop medication weeks or
months after the patient begins functioning normally
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Since learning of the unwanted side effects of
conventional antipsychotic drugs, clinicians have
become more careful in their prescription
practices
Newer Antipsychotic Drugs
• In recent years, new antipsychotic drugs have
been developed
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– Examples: Clozaril, Risperdal, Zyprexa, Seroquel,
Geodon, and Abilify
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Newer Antipsychotic Drugs
– They appear more effective than conventional
antipsychotic drugs, especially for negative symptoms
– They cause few extrapyramidal side effects and seem
less likely to case tardive dyskinesia
– They do, however, carry a risk of agranulocytosis, a
life-threatening drop in white blood cells
– They also may cause weight gain, dizziness, and
significant elevations in blood sugar
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• These new drugs are called “atypical” because
their biological operation differs from that of
conventional antipsychotics
Psychotherapy
• Before the discovery of antipsychotic drugs,
psychotherapy was not an option for people with
schizophrenia
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– Most were too far removed from reality to profit from
psychotherapy
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Psychotherapy
– The most helpful forms of psychotherapy include
cognitive-behavioral therapy and two broader
sociocultural therapies: family therapy and social
therapy
– These approaches are often combined
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Today, psychotherapy is successful in many
more cases of schizophrenia
• Form of cybertherapy where therapists have the
clients interact with computer-generated onscreen virtual human figures
• Can you think of any negative effects—shortterm or long- term—that might result from putting
a face on auditory hallucinations?
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Putting a Face on Auditory Hallucinations
Psychotherapy
• An increasing number of clinicians employ
techniques that seek to change how individuals
view and react to their hallucinatory experiences,
including:
• Provide education and evidence of the biological
causes of hallucinations
• Help clients learn about the “comings and
goings” of their own hallucinations and delusions
• Challenge clients' inaccurate ideas about the
power of their hallucinations
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Cognitive-behavioral therapy
Psychotherapy
• An increasing number of clinicians
employ techniques that seek to change
how individuals view and react to their
hallucinatory experiences, including:
• Teach clients to reattribute and more
accurately interpret their hallucinations
• Teach techniques for coping with their
unpleasant sensations
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Cognitive-behavioral therapy
Psychotherapy
• New-wave cognitive-behavioral
therapies also help clients to accept
their streams of problematic thoughts
• These techniques help patients gain a
greater sense of control, become more
functional, and move forward in life
• Studies indicate that these various
techniques are often very helpful
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Cognitive-behavioral therapy
Psychotherapy
• Over 50% of persons recovering from
schizophrenia and other severe disorder live
with family members
• This creates significant family stress
• Those who live with relatives who display
high levels of expressed emotion are at
greater risk for relapse than those who live
with more positive or supportive families
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Family therapy
Psychotherapy
• Family therapy attempts to address such
issues, create more realistic expectations, and
provide psychoeducation about the disorder
• Families may also turn to family support
groups and family psychoeducation programs
• Although research has yet to determine the
usefulness of these groups, the approach
has become popular
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Family therapy
Psychotherapy
• Many clinicians believe that the treatment of
people with schizophrenia should include
techniques that address social and personal
difficulties in the clients' lives
• These include: practical advice, problem
solving, decision making, social skills training,
medication management, employment
counseling, financial assistance, and housing
• Research finds that this approach reduces
rehospitalization
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Social Therapy
The Community Approach
– In 1963, Congress passed the Community Mental
Health Act, which said that patients should be able to
receive care within their own communities, rather than
being transported to institutions far from home
• This Act led to massive deinstitutionalization of patients with
schizophrenia
• Unfortunately, community care was (and is) inadequate for
their care
– The result is a “revolving door” syndrome
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• The community approach is the broadest
approach for the treatment of schizophrenia and
other severe mental disorders
• People recovering from schizophrenia and other
severe disorders need medication,
psychotherapy, help in handling daily pressures
and responsibilities, guidance in making
decisions, training in social skills, residential
supervision, and vocational counseling
– This combination of services sometimes is called
assertive community treatment
• Other key features are…
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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What Are the Features of Effective
Community Care?
What Are the Features of Effective
Community Care?
• Coordinated services
– Community mental health centers provide medications,
psychotherapy, and inpatient emergency care
– Coordination of services is especially important for
mentally ill chemical abusers (MICAs)
– If treatment on an outpatient basis is unsuccessful,
patients may be transferred to short-term hospital
programs
– After being hospitalized for up to a few weeks, patients are
released to aftercare programs for follow-up in the
community
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Short-term hospitalization
What Are the Features of Effective
Community Care?
– If patient needs fall between full hospitalization and
outpatient care, day center programs may be effective
– These programs provide daily supervised activities
and programs to improve social skills
– Another kind of institution that has become popular is
the semihospital, or residential crisis center – houses
or other structures in the community that provide 24hour nursing care for those with severe mental
disorders
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Partial hospitalization
What Are the Features of Effective
Community Care?
– Halfway houses (or group homes) provide shelter and
supervision for those patients who are unable to live
alone or with their families, but who do not require
hospitalization
– Staff are usually paraprofessionals
– Houses are run with a milieu therapy philosophy
– These programs help those with schizophrenia adjust
to community life and avoid rehospitalization
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Supervised residences
What Are the Features of Effective
Community Care?
– Paid employment provides income, independence,
self-respect, and the stimulation of working with
others
– Many people recovering from schizophrenia receive
occupational training in a sheltered workshop – a
supervised workplace for employees who are not
ready for competitive or complicated jobs
• An alternative work opportunity for individuals with severe
disorders is supported employment
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Occupational training and support
• There is no doubt that effective community
programs can help people with schizophrenia
and other severe mental disorders recover
• However, fewer than half of all people who need
them receive appropriate community mental
health services
– In any given year, 40% to 60% of all people with
schizophrenia receive no treatment at all
– Two factors are primarily responsible:
• Poor coordination of services
• Shortage of services
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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How Has Community Treatment Failed?
How Has Community Treatment Failed?
– Mental health agencies in a community often fail to
communicate with one another
– To combat this problem, a growing number of
community therapists have become case managers
for people suffering from schizophrenia
• Case managers offer therapy and advice, teach problemsolving and social skills, and ensure compliance with
medications
• Case managers also try to coordinate available community
services for their clients, guide them through the system and
protect their legal rights
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Poor coordination of services
How Has Community Treatment Failed?
– The number of community programs available to
people with schizophrenia falls woefully short
– The centers that do exist generally fail to provide
adequate services for people with severe disorders
– While there are various reasons for these shortages,
the primary one is economic
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Shortage of services
What Are the Consequences of Inadequate
Community Treatment?
– Many return to their families and receive medication
and perhaps emotional and financial support, but little
else in the way of treatment
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• When community treatment fails, many people
suffering from schizophrenia and other severe
mental disorders receive no treatment at all
• Around 8% of patients enter an alternative care
facility (such as a nursing home), where they
receive custodial care and medication
• As many as 18% are placed in privately run
residences where supervision is provided by
untrained individuals
• Another 34% of patients are placed in singleroom occupancy hotels, generally in rundown
environments, where they survive on
government disability payments
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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What Are the Consequences of Inadequate
Community Treatment?
What Are the Consequences of Inadequate
Community Treatment?
• Finally, a great number of people suffering from
schizophrenia become homeless
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– Approximately one-third of the homeless people in
America have a severe mental disorder, commonly
schizophrenia
Abnormal Psychology | Ronald J. Comer | Ninth Edition
The Promise of Community Treatment
– In addition, a number of national interest groups,
including the National Alliance on Mental Illness
(NAMI), have formed to push for better community
treatment
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Despite these very serious problems, proper
community care has shown great potential for
assisting in recovery from schizophrenia
• Today, community care is a major feature of
treatment for people recovering from severe
mental disorders in countries around the world
• Both in the U.S. and abroad, varied and wellcoordinated community treatment is seen as an
important part of the solution to the problem of
schizophrenia
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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The Promise of Community Treatment
• Experts say U.S. prisons and jails have become the
country’s largest mental health institutions, its new
asylums.
• Nearly four times more Californians with serious
mental illnesses are housed in jails and prisons than
in hospitals
• 16 to 20 percent of prisoners are mentally ill
• Why is it shortsighted—both morally and
financially—for government officials to stop funding
mental health treatment courts and similar
programs?
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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“Alternative” Mental Health Care