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PSYC 690J3 (29)
Juan Wang (29)

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PSYC 690J3
Juan Wang

Current issues and new direction  Relapse prevention is one of the most imp goals of long term mgt of s. relapse is both distressing and costly. Poor adherence to meds is a primary cause of relapse and re hospitalization  As high as 80% of ppl are unable or unwilling to take meds as directed  Approx 75% of ppl discontinued the assigned meds due to lack of efficacy, intolerability or both  Another reason for poor adherence is ppls poor insight into their disorder however problems related to accessing prescriptions, obtaining refills and simply forgetting to take meds play a role too  Nonadherent ppl with s are 5 times more like to relapse than those who adhere to prescribed regimens  They found a significant reduction in the replase rate among ppl who took the atypical antip. The average relapse rate with haloperidol was 23% whereas the rate for the group of 2 generation drugs averaged only 15%. This is a clinically significant effect  Atypical meds appear to give s patients better quality of life  A variety of long term injectable meds have been develop. They have potential benefits including increased adherence and decreased relapse but also less liver toxicity and decreased adverse effects. Long lasting risperidone is administered intramuscularly every 2 week  Ability 2 function independently in the community has not improved significantly.  Should be more focus on negative and cognitive symp since they are more strongly associated with social and occupational functioning  Neurocognitive deficits were assessed in 8 domains. The hypothesis that olazapine treatment would produce greater neurocognitve benefits after 52 weeks than risperidone or haloperidol tretannt was not confirmed since the 3 meds did not differ in their neurpognitve efficacy.  Olanzapienn and risperidone treated patients improved on several domains including executive function, learning/memory, processing speed, attention/vigilicamce, verbal working memory, and motor functions.  Risperidone treated patients improved on domains of visuosptail memory.  Haloperidol treated ppl improved only on domains of learning/memory  Concluding that patients benefit most from olamnzapine and risperidone  Aripiprzaole and perphenazine concludeed that both meds can improve the symp in treatment resistant pl who did not response to olazine or risperdine  There’s a huge urge to figure out whether high mortality in s is due to disorder itself or due to meds  Dopamine dysregualtion may provide the driving force but the subjects cognitive psychodynamic and cultural context gives form to the experience. ----Biopsychosocial model Psychological treatments  Recent evidence indicates that psych strategies can play an imp role in increasing the effectiveness of meds treatment and decreasing relapse rate Social skills training  designed to tech ppl with s beh that can help them succeed in a wide variety of interpersonal situations  Is usually a component of treatments for s that go beyond Family therapy and reducing expressed emotion  Show that high levels of expressed emotion (including being hostile, hypercritical, and overprotective within the family) have been linked to relapse and re hospitalization  Educate ppl and families about s specially about the bio vulnerability hat predisposes some ppl to the illness, cog problems inherent to s, the symp of the illness and signs of impending relapse  They provide info about an advice on the monitoring of the effects of antip meds  They encourage family members to blame neither themselves not the patient for the illness and the for the difficulties all are having in coping with it  They help improve communication and problem solving skills within the family  They courante ppl as well as their family to expand their social contact, esp their support networks  They instil a degree of hope that things can improve including the hope that the patient may not have to return to the hospital  Compared with standard treatment family therapy plus meds has typically lowered relapse over periods of 1-2 years. This positive finding is evident in studies in which the treatment lasts for at least 9 months Cognitive behavioural therapy  S can benefit from cog techniques designed to address their delusions and hallucinations  That CBT plus enriched treatment as usual is as effective as treatment as usual alone and that CBT seems to be particularly effective at reducing negative symp of s  Two key goals are to help the patient reframe the psychosis (help him or her develop a cognitive understanding of the psychosis ) and self identify triggers for the psyhcis  Other interventions involve teaching patients how to reduce physiological arousal, enhance their coping skills and modify aberrant beliefs directly  Support the efficacy of individualized CBT for ppl with persistent positive psychotic symp. However the efficacy of a group format is less clear cut  CBT is probably not the optimum treatment for reducing hallucinations and delusions though it possibly has imp benefits including feeling less negative about oneself and less hopeless for the future  Although education and family therapy types of programs were generally ineffective programs based on CBT principles were more effective Personal therapy  Personal therapy is a broad spectrum CBT approach to the multiplicity of problems of ppl with s who have been discharged from hospital. This therapy is conducted both one on one and in small groups. A key element based on the finding of EE research that a reduction in emotional reactions by family members leads to les relapse following hospital discharge is teaching the patient how to recognize inappropriate affect  Patients are also taught to notice small signs of relapse such as social withdrawal or inappropriate threats against others and they learn sills to reduce these problems  The therapy also includes some rational emotive beh therapy to help pl avoid turning life’s inevitable frustrations and challenges into catastrophes and this to help them lowers their stress levels  Many ppl are taught muscle relaxation as an aid to detecting the gradual build-up of anxiety or anger ; they also learn how to apply the relaxation skills in order to control these emotions better  The assumption is that emotional dysregulation is part of the biological diathesis in s and a factor that patients must learn to live and cope with rather than eliminate altogether. But there is also a strong focus on teaching specific social skills as well as on encouraging patients to continue to take their antip meds in a maintenance mode that is in a dose that is typically lower than what is necessary in the earliest, acute and most florid phase of the illness  Personal therapy includes non beh elements esp warm and empathic acceptance of the patients emotional and cognitive turmoil along with realistic but optimistic expectations that life can be better. In general patients are taught that they emotionally vulnerable to stress that their thinking is not always as clear as it should be, that they have to continue wit their med and that they can learn a variety of skills to make the most of the hand that nature has dealt them. This is not a short term treatment; it can extend over 3 yrs of weekly to biweekly therapy contacts  Note that much of the focus is on the patient not on the family. Whereas the focus in the family studies was on reducing the high EE of the patients family—an environmental change from the patients point of view—the goal of personal therapy is on teach the patient internal coping skills new ways of thinking about and controlling his or her own affective reactions to whatever challenges are presented by his or her environment. Specific instruction in social skills is also as an integral part of treatment  Finally this therapy is imp cuz of what hogarty et al call criticism mgt and conflict resolution. This phase refers to learning how to deal with negative feedback from others and how to resolve the interpersonal conflicts that are an inevitable part of dealing with others Treatment focus on basic cognitive functions  Have deficits in virtually all facets of cognitive functioning and show performance deficits on a range of simple an complex tasks  Moreover these deficits are apparent in 1 episode, non medicated patients so deficits are not a by product of receiving treatment  To use pyshc means to enhance basic cognitive functions such as verbal learning ability. Another goal is to construct intervention strategies that make maximum use of those cognitive functions that remain relatively intact in s such as the ability to understand and remember what is presented in a picture  Drug Therapy that positive clinical outcomes from olanzapine and risperdone are associated with improvements in certain kinds of neurocognive functions lending support to the more general notion that paying attention to fundamental cognitive processes---the kind that non clinical cognitive psychologists study---holds promise for improving the social and emotional lives of ppl with s  An approach called cognitive enhancement therapy (CET). Specific focus is on computer based training in attention, memory and problem solving as well as social cognitive skills . CET provided successful in improving cognition and processing speed and there was some evidence to suggest that it has also had a positive effect on some functional outcomes  Other recent studies have shown that a s patients ability to recognize facial affect in others working memory and attention can all be improved though cognitive training.  Zakzanis; has demonstrated the utility of scaffolding in the remediation of
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