Treatment

1. Treatment

2. 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

3. 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)

4. Test Yourself • Which part of the brain is often enlarged in schizophrenics? • amygdala • hippocampus • basal ganglia • orbitofrontal cortex • ventricles

5. 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

6. 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

7. Psychopharmacology: Antipsychotics Antipsychotics • mainly dopamine-based • undesirable side effects • may not help negative symptoms of schizophrenia • side effects • tardive dyskinesia • 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 DEINSTITUTIONALIZATION

8. 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

9. 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 • 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

10. Miracle drug or personality pill?

11. 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?

12. 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

13. 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

14. 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 • anesthesia • muscle relaxants • unilateral stimulation to reduce retrograde memory loss • why does it work? • ??? Jack Nicholson as McMurphy in One Flew Over the Cuckoo’s Nest undergoes ECT and ultimately a lobotomy

15. 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

16. 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

17. Psychotherapy • Most modern day therapists use an eclectic approach -- a bit of everything

18. 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

19. Humanistic Therapy ASSUMPTIONS • People are good and have innate worth GOALS • to promote personal growth and self-actualization • 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, non-judgmental atmosphere in which client is worthy and capable

20. 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.

21. 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

22. 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

23. 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.

24. 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)

25. 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

26. Systematic Desensitization

27. 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 formally-trained leader (e.g., AA) • Marital and Family Counselling • work on interactions

28. 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

29. Different problems, different solutions

30. 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

31. 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

32. 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

33. 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