Psychotic Disorders III April 25, 2014 PSYC 2340: Abnormal Psychology Brett Deacon, Ph.D.

1. Psychotic Disorders IIIApril 25, 2014PSYC 2340: Abnormal PsychologyBrett Deacon, Ph.D.

2. Announcements • Please complete online course evaluations! • Remaining schedule

3. From Last Class • Schizophrenia • Prevalence • Causal influences • Antipsychotic use – prevalence (overall, children, military, etc.)

4. Medications • Antipsychotic (Neuroleptic) Medications • Discovered by accident in the 1950s (along with drugs for depression, mania, inattention, and anxiety) • Most reduce positive symptoms • Poor compliance is common • Better compliance is associated with better outcomes • Clinical emphasis on accepting one has a chronic disease and needs to always take medication

5. Medications • Antipsychotic medications are not beneficial in reducing the negative symptoms of schizophrenia • In fact, they cause them: Negative Signs and Symptoms Secondary to Antipsychotics: A Double-Blind, Randomized Trial of a Single Dose of Placebo, Haloperidol, and Risperidone in Healthy Volunteers http://ajp.psychiatryonline.org/article.aspx?Volume=163&page=488&journalID=13 • CONCLUSIONS: Single doses of both haloperidol and risperidone produce negative symptoms in normal individuals. Drowsiness may be an important confounding factor in the assessment of negative symptoms in antipsychotic trials.

6. Medications • Acute effects of antipsychotics: • Deactivation syndrome: “disinterest, indifference, diminished concern, blunting, lack of spontaneity, reduced emotional activity, reduced motivation and will, apathy in the extreme” (Breggin, 1993) • Symptoms experienced by healthy volunteers in Healy and Farquhar (1998): motor restlessness, irritability, impatience, “a general feeling common to all subjects to some extent of disengagement – a feeling of uninvolvement with the tasks at hand, mental effort appeared to be difficult, with all subjects reporting some problems with concentration. Apparently simple tasks, such as obtaining a sandwich from a sandwich machine, proved too difficult for some people.”

7. Medications • Severe side effects (acute and permanent) • Marked weight gain/obesity (Correll et al., 2010) • Diabetes • Hypertension and cardiovascular problems • Physical symptoms – fatigue, drowsiness, blurred vision, dry mouth • Antipsychotics were formerly known as “major tranquilizers” for a reason

8. Benefits of a Major Tranquilizer (ads for Thorazine)

9. Medications • “Extrapyramidal symptoms” – Parkinson-like side effects • Akinesia – expressionless face, slow motor activity, monotonous speech • Tardive dyskenesia – involuntary movements of tongue, face, mouth, or jaw; usually irreversible • Prevalence: 32% after 5 years, 57% by 15 years, 68% by 25 years (Glazer et al., 1993) • http://www.youtube.com/watch?v=R0EbgpyztCA&feature=related • http://www.youtube.com/watch?v=n1CesjByFFw

10. US Prescriptions of Antipsychotics for People Younger than 21: 1993 to 2002 Olfson, Blanco, Liu, Moreno, & Laje (2006)

11. Older Antipsychotics vs. Atypical Antipsychotics • Newer drugs initially thought to be more effective and have fewer adverse effects. Not true. • The NIMH-funded Clinical Antipsychotic Trials of Intervention Effectiveness study failed to demonstrate significantly greater short- or long-term efficacy of olanzapine, quetiapine, risperidone, ziprasidone, all blockbuster atypical antipsychotics, over a neuroleptic medication whose therapeutic benefits for psychosis were first described in 1957 (Lieberman et al., 2005). Similar findings were reported with children and adolescents in the NIMH-sponsored Treatment of Early-Onset Schizophrenia Spectrum study (Sikich et al., 2008). In both investigations, more than 70% of patients eventually stopped taking the assigned medication due to lack of efficacy or intolerable adverse effects.

12. Long-Term Efficacy of Schizophrenia Treatments • Jablensky et al. (1992): World Health Organization 2-year follow-up study of 1,379 patients in 10 countries • Developing countries: India, Columbia, Nigeria, Czech Republic • Developed countries: Denmark, Ireland, US, USSR, Japan, UK

13. WHO Study Results Note: 61% of patients in developing countries took antipsychotics for the duration of the follow-up, compared to 15.9% in developing countries.

14. Long-Term Efficacy of Antipsychotics • Harrow and Jobe (2007), NIMH-funded 15-year follow-up study of 64 patients in Chicago with schizophrenia • At the end of 15 years, 40% of those who had stopped taking antipsychotics were recovered • 5% of those who remained on antipsychotics were recovered • Global functioning twice as high for unmedicated vs. medicated patients

15. Long-Term Efficacy of Antipsychotics • What is the evidence base? • How should it be interpreted? • Doe conventional wisdom match the data? • Robert Whitaker on Harrow’s study (41:20): http://www.youtube.com/watch?v=VgS79hz1saI

16. The World’s Best Treatment for Schizophrenia • Open Dialogue approach in Finland: • http://www.youtube.com/watch?v=aBjIvnRFja4 • Complete film: http://www.youtube.com/watch?v=HDVhZHJagfQ(54:00)

17. Psychosocial Treatment • Deinstitutionalization and its consequences

18. Psychosocial Treatment • Psychosocial approaches: • Behavioral approaches (i.e., token economies) on inpatient units • Community care programs • Cognitive-behavioral therapy • Supported employment • Social and living skills training • Vocational rehabilitation

19. UK’s National Institute for Clinical Excellence (NICE) Clinical Practice Guidelines (2009) • Psychological treatment: http://www.nice.org.uk/nicemedia/live/11786/43610/43610.pdf • “Offer cognitive behavioural therapy (CBT) to all people with schizophrenia. This can be started either during the acute phase or later, including in inpatient settings. • Offer family intervention to all families of people with schizophrenia who live with or are in close contact with the service user. This can be started either during the acute phase or later, including in inpatient settings.”

20. UK’s National Institute for Clinical Excellence (NICE) Clinical Practice Guidelines (2009) • “Deliver CBT on a one-to-one basis over at least 16 planned sessions. Follow a treatment manual so that: • people can establish links between their thoughts, feelings or actions and their current or past symptoms, and/or functioning • re-evaluation of people’s perceptions, beliefs or reasoning relates to the target symptoms. • CBT should include at least one of the following components: • people monitoring their own thoughts, feelings or behaviors with respect to their symptoms or recurrence of symptoms • promoting alternative ways of coping with the target symptom • reducing distress • improving functioning”

21. Psychosocial Treatment • How often do patients with schizophrenia receive psychological treatments? • For Medicaid patients, 23.4% of those with schizoaffective disorder • 13.0% with schizophrenia (Olfson et al., 2009)

22. Review of Treatment Studies from 1980-1992

23. Exam #4 • 40 questions • 18 on personality disorders • 22 on psychosis