Treatment of Psychological Disorders

1. Treatment of Psychological Disorders History Psychological Therapies Biological Therapies Effectiveness Specific Disorder-Treatment Matches

2. Old-Fashioned Causes & “Cures” • Possession by demons • Prehistoric • Trephination • In league with Satan • Up to 1700 • Exorcism • Torture • Starvation • Humor imbalance • From Greeks until 1800s • Bloodletting • Purging • Whirling • Illness • Middle ages until 1800’s • Confinement in asylums, often dungeon-like prisons

3. History: 1800’s to 1950 • Humanitarian Reform Movement (1800’s) • “Inmates” begin to be housed in more standard living conditions • Hysteria and general paresis • Hysteria cured by Freud (1890’s) • Psychological approach to treatment • General paresis caused by syphilis (1913) • Neuropsychiatric disorder affecting central nervous system • Presents with psychotic-like symptoms • Biological approach to treatment • Mental hospital inpatient population grows to 600,000 in 1950’s (see slide 5)

4. History: 1950’s to present • Discovery of antipsychotics in 1950’s • Deinstitutionalization begins in 1960’s and continues until today • 40,000 mental hospital inpatients remain (see slide 5) • Some reasons for deinstitutionalization • Introduction of antipsychotics • Criticism of mental hospitals • Community care movement • Reduce costs to state governments • Some negative consequences of deinstitutionalization • 16% - 50% of incarcerated prisoners have a mental disorder • The range in percentages depend on criteria for mental disorder classification • 1/3-1/2 of homeless have mental disorders • Jack Nicholson in “One Flew over the Cuckoo’s Nest”

5. Antipsychotic Drugs & Inpatients

6. Psychological Therapies(Psychotherapy) Psychodynamic Therapies Humanistic Therapies Behavioral Therapies Cognitive Therapies Group-Therapy Approaches

7. Psychodynamic Therapies I • The goal is to uncover and resolve conflicting thoughts, feelings, and intentions • Insight: an understanding of one’s own psychological processes • Free association • Dream analysis: manifest vs. latent content • Hypnosis • Analysis of resistance • Resistance is the barriers to free association and treatment in general that the patient creates. • Catharsis: recovery into consciousness of repressed mental contents causes release of psychic energy and the melting away of associated symptoms

8. Psychodynamic Therapies II • Therapeutic alliance • Patient-Therapist relationship • Comfort level • Nonjudgmental and empathetic listener • Transference • Patients bring enduring interpersonal patterns into their relationship with their therapist • Positive vs. negative • Countertransference • Therapists may experience emotional responses to their patients • Therapist must themselves undergo therapy in order to detect and handle these feelings

9. Humanistic Therapies • Removing impediments to personal growth • Client-Centered Therapy – Carl Rogers • Warm and Caring Relationship • Empathy • Unconditional Positive Regard • Reflection • Gestalt Therapy – Fritz Perls • Empty chair technique • Imagine that the person to whom you wish to express your feelings is sitting in the empty chair • Two chair technique • Place two sides of a dilemma in two different chairs and express each side while in that chair

10. Behavioral Therapies I • Focus is on altering symptoms rather than exploring their meaning • Operant-Conditioning Techniques • Reward and Punishment • Behavior modification • Token economies • Biofeedback • To treat headaches or chronic pain (see next slide) • Skills Training • Social skills • Assertiveness training • ADHD

11. Biofeedback & Tension Headaches • Sensors on the head detect muscle activity • System converts signal to visual display • Patient watches the display, tries to reduce tension signal • Muscle tension reduced

12. Behavioral Therapies II • Classical conditioning techniques are often used when there is a specific feared object (as in phobias) or desired object (as in addictions) • Flooding • Confronting a fearful stimulus without negative consequences will lead to extinction of the dysfunctional conditioned emotional response • Systematic Desensitization • Associating positive feelings with a feared stimulus • Relaxation training, construction of fear hierarchy, and gradual exposure • Aversive Conditioning:associating negative feelings with a desirable, but unhealthy, object (see next slide)

13. Aversion Therapy for Alcoholism • Alcohol is paired with a chemical that causes nausea and vomiting • Straightforward classical conditioning

14. Cognitive Therapies I • Rational-Emotive Behavior Therapy • Albert Ellis • A form of cognitive therapy in which people are confronted with their irrational, maladaptive beliefs. • Common beliefs that are irrational and self-defeating • I have to be liked by everyone • I have to be perfect at what I do • Everyone gets what they deserve • Therapeutic devices • Step out of character • “How to refuse to be ashamed of anything” • Try new behaviors to see that these behaviors won’t bring your life crashing down around you

15. Cognitive Therapies II • A-B-C’s of Emotional Distress • Disorders often occur because of self-defeating beliefs • Activating Event - Beliefs - Consequences • Rational-emotive therapy helps people change these beliefs

16. Cognitive Therapies III • Cognitive Therapy • Aaron Beck • A form of psychotherapy in which people are taught to think in more adaptive ways. • Address cognitive distortions • Catastrophizing: belief that was has happened was so awful or what will happen will be so terrible that you won’t be able to stand it • Overgeneralization: seeing a single negative event as a never-ending pattern of defeat • Address negative triad (world, self, future) in depression • World: interpret events unfavorably • Self: Does not like themselves • Future: Regard future pessimistically • Therapeutic devices • Asking “What’s the evidence?” “Are these facts or interpretation?” “Is there another way to look at the situation?” • Triggering distress during therapy so that it can be interpreted • Keeping diaries or logs and doing reading assignments

17. Group Therapy Approaches • 4 to 10 people meet with one or two therapists usually once a week for 2 hours • Successful group members can instill hope in newcomers • Discovering that others have similar problems can relieve shame and guilt • Group members talk about individual problems, but also gain insight from group processes in that people often interact with others in such a way that it is revealing

18. Biological Therapies Drug Therapies (uses psychotropic medications) (also known as Psychopharmacology)

19. Antianxiety Drugs • “Tranquilizers” • Can treat generalized anxiety • Barbituates • Work, but are highly addictive • Benzodiazepines • Increase activity of GABA, an inhibitory neurotransmitter • Examples (trade names in parentheses) • Diazepam (Valium) • Chlordiazepoxide (Librium) • Alprazolam (Xanax) • Negative side effects • Drowsiness; dangerous when combined with alcohol • After stopping, two-week rebound period of greater anxiety • Can be psychologically and physically addictive • Can cause memory loss • Buspirone (Trade name: BuSpar)

20. Antidepressants • Tricyclic antidepressants • Block reuptake of serotonin and norepinephrine • Improvement of 40-50% over placebo • Imipramine (Trade name: Tofranil) • Placebo: Any medical intervention designed to work through the power of suggestion • A pill that does not contain any medically active ingredients can reduce symptoms by 20-40% • MAO (monoamine oxidase) inhibitors • MAO is an enzyme that breaks down serotonin • So, if you inhibit this enzyme, you will increase the amount of serotonin in the brain • Effective when personality disorders are also present • Selective serotonin reuptake inhibitors (SSRI’s) • Fluoxetine (Trade name: Prozac)

21. Antipsychotic Drugs • “Major tranquilizers” • Known as this because of sedating effects • Also known as “neuroleptics” • Reduce positive symptoms, like hallucinations and delusions • By inhibiting dopamine • Do not do much for negative symptoms • Examples (trade name in parentheses) • Chlorpromazine (Thorazine) • Haloperidol (Haldol) • Clozapine (Clozaril) • Risperidone (Risperdal) • Side effects of thorazine: tardive dyskinesia • Involuntary twitching in tongue, face, neck, and jaw • Occurs in patients who have taken Thorazine for several years • Irreversible

22. Other Medical Interventions • Electroconvulsive Therapy (ECT) • Electric-shock treatments that often relieve severe depression by triggering seizures in the brain. • Psychosurgery • The surgical removal of portions of the brain for the purpose of treating psychological disorders. • After, antipsychotic medications were introduced, psychosurgery was no longer a serious consideration • Lobotomy • Severing tissue in a cerebral lobe, typically the frontal lobe • Produced severe side effects (see Phineas Gage)

23. Treatment Effectiveness Psychotherapy Disorder-Treatment matches

24. Usefulness of Psychotherapy • Two ways to evaluate the usefulness of psychotherapy • Effectiveness studies (this slide) vs. efficacy studies (next slide) • Effectiveness studies • Assessment of treatment outcomes under relatively less controlled conditions • 1994 Consumer Reports Survey (N=2900) • Somewhat improved to much improved – 86% • Fairly satisfied to highly satisfied – 89% • 2004 Consumer Reports Survey (N=3000) • 28% rise in the use of psychological medications • Medication plus psychotherapy produces the best outcome, followed by psychotherapy alone, and then drug therapy alone • Reasons to be critical of the use of effectiveness studies • Subjective measure • No comparison to group that had problems but did not receive treatment

25. Efficacy studies • Assessment of treatment outcomes under controlled conditions • Random assignment of subjects to conditions • Therapists trained to adhere to manual • Standardized length of treatment • Summary of 475 efficacy studies (Smith et al., 1980) • The figure below shows that the average psychotherapy patient is better off than 80% of untreated patients

26. Are some psychotherapies better? • On average, across all disorders, all therapies are equally effective (Sloane et al., 1977; Elkin et al., 1989) • However, for some disorders, certain types of therapy tend to be more successful than others • Two common, nonspecific factors at work in all types of psychotherapy • Supportive relationship with caring therapist gives patients reason for hope • The opportunity for a patient to open up can have healing power • Pennebaker

27. Anxiety Disorder & Treatment Match • For specific phobias • The sources of anxiety are better addressed with cognitive-behavioral therapy (CBT) than with medication • Systematic Desensitization • Virtual treatments can reduce fear responses • For social phobia • SSRI’s help, but CBT is better • For panic disorder • Treatments often combine medication and CBT, but relapse is less with CBT • For obsessive-compulsive disorder (OCD) • For tic-related OCD, SSRI’s and dopamine receptor blockers • For non-tic-related OCD, oxytocin regulation • Exposure and response prevention therapy

28. Exposure & Response Prevention • Another type of behavioral therapy • Woman with hand-washing compulsion • Baseline - Instruction - Response prevention cycle • After a few cycles, the woman was washing less often and getting fewer urges to wash Hand washing Urges

29. Depression & Treatment Match • Psychological medications • MAO-inhibitors, tricyclics, and SSRI’s provide relief to 60-70% of depressed persons • Cognitive-behavioral therapy (CBT) • Just as effective psychological medications • Targets the automatic irrational thoughts that accompany depression • Medication plus CBT is most effective • Seasonal Affective Disorder • Responds to phototherapy • Exercise helps depression too • Electroconvulsive therapy (ECT) • The single most effective treatment for severe depression, and it saves lives, negative public views notwithstanding • Transcranial magnetic stimulation (TMS)

30. Bipolar Disorder & Treatment Match • Lithium is “indispensable” for the treatment of bipolar disorder • Reduces bipolar mood swings • Especially effective at calming mania • Less effective in reducing the severity of the depressive mood swings • For this reason, an antidepressant is often prescribed in addition to lithium • Takes awhile (3-4 weeks) to “kick in” • Side effects are unpleasant during this period • Highly toxic • Only 20% of bipolar patients who maintain their medications experience relapse • But many patients discontinue medication, perhaps because of the “intoxicating pleasure” of manic states

31. Schizophrenia & Treatment Match • Antipsychotic medications are indispensable for the treatment of schizophrenia • But significant sedative and motor side effects, resembling Parkinson’s disease, make treatment unpleasant for many patients • In addition, patients show little improvement in social skills • Psychosocial treatments • Improve functioning beyond drug treatments • Social skills training • Most schizophrenic patients improve as they get older

32. Professionals Involved in Therapy • Clinical Psychologists • Psychiatrists • Psychiatric (or clinical) social worker • Psychiatric nurse • Counseling Psychologists • Psychoanalysts • Others offering therapy (paraprofessionals) • Crisis intervention • Pastoral Counselors • Community outreach

33. Where People Turn for Help

34. Orientations of Psychotherapists

35. Can Personality Disorders Be Treated? • Dialectical Behavior Therapy Is Most Successful for Borderline Personality Disorder • Antisocial Personality Disorder Is Difficult to Treat

36. The Use of Medication to Treat Adolescent Depression Is Controversial • Fewer than 30 percent of children who have mental health problems receive any type of treatment • Twice as many of those taking SSRIs reported having suicidal thoughts (4 percent) as those taking a placebo (2 percent) • None of the children or adolescents committed suicide • The FDA voted in 2004 to require manufacturers to add to their product labels a warning that antidepressants increase the risk of suicidal thinking and behavior in depressed children and adolescents

39. The Use of Medication to Treat Adolescent Depression Is Controversial • The previous slide displayed the results of the TADS study • All treatment groups experienced a reduction in thoughts of suicide compared with the baseline • However, participants in the Prozac group were twice as likely to have serious suicidal thoughts or intentions compared with those undergoing other treatments • Although prescribing drugs without CBT might be cost effective, it may not be in the best interests of depressed children

40. Children with ADHD Can Benefit from a Variety of Approaches • Methylphenidate (ritalin) targets under active brains and reduces negative behaviors (see Fig. 14.29 and Fig. 15.23) • Side effects and lack of long-term efficacy limit the utility of ritalin • Behavioral Treatments, though time-consuming, augment medication and help social skills, academics, and family relationships

41. Autistic Children Benefit from a Structured Treatment Approach • Generalization of skills must be taught explicitly • Applied Behavior Analysis (ABA) is time intensive but raises IQ points by 20 on-average • The long-term prognosis for autism is poor