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Chapter 17

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University of Toronto Mississauga
Hywel Morgan

PSY240 –Chapter17Notes Therapies Biological Treatments  Practices like bleeding (cuts/leeches) designed to correct biological imbalances presumed to underlie psychological symptoms  Disturbed patients protected from self-harm thru physical restraints, long warm baths, or placed under cold packs  Two current treatment options: electroconvulsive therapy (controversial) and psychopharmacology (common)  Other options that show encouraging results: light therapy, repetitive trans cranial magnetic stimulation, and deep brain stimulation for depression ELECTROCONVULSIVE THERAPY  1930s: clinicians noticed that patients with schizophrenia who spontaneously experienced epileptic seizures showed a reduction in schizophrenic symptoms o Reasoned that provoking seizures would reduce psychotic symptoms o Seizures provoked by application of electric current to temples (electroconvulsive therapy, ECT)  ECT abandoned with advent of antipsychotic medication for treatment of schizophrenia o Still used to treat severe depression that has not responded to other treatments  especially for older adults and medically ill patients  Used to be associated with serious side effects, incl. disorientation + memory loss, broken bones, death (rare cases) o Adverse effects minimized thru less intense, briefer currents (one side of brain), shorter courses of treatment o Now most commonly reported side effect is retrograde amnesia, mortality rate reduced to 2/100 000 o Anaesthesia + muscle relaxants reduce distress + risk of injury, patients monitored during procedure and get full medical + neurological evaluation before receiving ECT o Ontario 1999-2005: patients receiving ECT from 7800-10 800  Consistent evidence for short-term efficacy of ECT in treating adult patients with depressive disorders o More than 50% however likely to relapse o Most effective types of ECT delivery associated with greatest risk of cognitive impairment o ECT considered appropriate only in treatment of life-threatening severe depression not responding to other treatment PSYCHOPHARMACOLOGY  Pharmacological agents that affect the individual’s psychological functioning are known as psychoactive agents  64 853 000 prescriptions for psychotherapeutic drugs were issued in Canada in 2010, second only to the number of prescriptions issued to treat cardiovascular problems  ideal method for developing new medications first to understand the pathological process by which a disorder develops, then identify agent that will change that process TABLE 17.1 MEDICATION TRIALS  Placebo: An inert substance associated with alleviation of symptoms through expectancy effects  Active placebo: A therapeutically inert substance with the same side effects as the medication  Placebo washout: The first phase of a clinical trial, in which all participants are given a placebo and those who respond to the placebo are dropped from the study  Single-blind trial: The first phase of a clinical trial, in which all participants are given a placebo and those who respond to the placebo are dropped from the study  Double-Blind Trial: A clinical trial in which both the patient and the clinician are unaware of whether the patient is receiving medication or placebo  Randomized controlled trial: A clinical trial in which patients are randomly assigned to either a placebo or a medication condition, and the results of the two conditions are statistically compared  medication trials are conducted to systematically assess drug efficacy  important differences between the conditions in medication trials and the conditions in which these medications are subsequently prescribed  We cannot assume that drugs will have the same effects in general practice as they do in clinical trials.  Evidence that some drugs that are effective in one age group may not be suitable for administration to other age groups, such as older adults  Group drugs here according to their application in the treatment of different types of disorder: antipsychotic, antidepressant, anxiolytic (anti-anxiety), mood-altering, and psycho-stimulant ANTIPSYCHOTICS  development in the 1950s  Phenothiazine’s and related major tranquilizers offered the possibility of reducing psychotic symptoms such as hallucinations  Following stabilization on the drug, formerly institutionalized patients able to return to community (policy of deinstitutionalization)  Economic benefits and advent of antipsychotic medication = major breakthrough.  Schizophrenia is a chronic disorder, patients must adhere to a long-term medication regimen.  Antipsychotics do not cure instead they control symptoms. Dosage carefully calibrated maximize symptomatic control minimize side effects.  Many patients are tempted to discontinue their medication when they are feeling symptom- free, increasing the risk of a relapse o Medication can be delivered via long-acting intramuscular injection rather than oral meds  Some patients experience extrapyramidal effects similar to symptoms of Parkinson’s disease, incl. stooped posture, muscular rigidity, distinctive shuffling gait, and occasional drooling o Side effects may be relieved by anti-Parkinsonian drugs (have separate side-effects) o Tardive dyskinesia extrapyramidal effects incl. eye twitching and tongue thrusting  New generation of antipsychotic meds: clozapine and olanzapine have fewer extrapyramidal effects but associated with other side effects such as weight gain o no evidence that newer generation of drugs more efficacious that older (less-expensive) ones o 2 generation anti-psychotics have mood-stabilizing properties, which may make them effective in the treatment of bipolar disorder  choice of antipsychotic medication should be based on side effects in the individual patient ANXIOLYTICS  used to alleviate symptoms of anxiety and muscle tension by reducing activity in parts of the central nervous system, lowering activity in the sympathetic nervous system = lower respiration and heart rate + decreased muscle tension  first class of anxiolytic drugs: barbiturates o patients develop tolerance for them, requires larger doses over time to achieve same effect o large doses = highly toxic, common choice for suicide attempts  second class of anxiolytics: benzodiazepines o offer effective control of anxiety without toxicity at high doses o also addictive, after prolonged use, sudden withdrawal can provoke life-threatening convulsions o dose is gradually reduced, patients must be monitored carefully o dangerous when taken in combination with alcohol o should only be used in brief periods in the treatment of anxiety disorders ANTIDEPRESSANTS  four major categories of drugs: o MAOIs (Monoamine oxidase inhibitors  Common foods such as yeast, chocolate, and beer that contain enzyme tyramine can cause life-threatening increase in blood pressure with this drug o TCAs (tricyclic’s)  Provoke many unpleasant side effects such as dry mouth, blurry vision, constipation, and light-headedness o SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors)  Most recently developed groups; Prozac best known  Comparable in efficacy of TCAs for adults  May be better tolerated than TCAs, still cause side effects such as nausea, diarrhea, headache, tremors, and sleepiness  Similar side effects with SNRIs and flu-like symptoms can occur if SNRIs are stopped abruptly  Risk of adverse outcomes in older adults is greater with SSRIs than TCAs  Canadian guidelines recommend SSRIs and SNRIs as first-line medication options  Antidepressants take time to reach beneficial levels in the blood, so improvement is typically evident only after one to two weeks of treatment, with optimal response by the third of fourth week o 30-50% of patients do not respond favourably to antidepressants  Will respond favourably to a different class o Why most people discontinue using them within three month of starting medication  Antidepressants bring symptomatic relief to many adults in the acute phase of a depressive disorder  Benefits of antidepressants most pronounced in those with severe depression, but only minimal/ non-existent at mild and moderate levels of symptom severity  Treatment research indicates that benefits of antidepressants for youth outweigh risks of suicidal behaviour MOOD STABILIZERS  Lithium salts medication of choice for bipolar, although use decreased in favour of other mood stabilizers and newer antipsychotics  Lithium + related mood stabilizers reduce rapid cycling between depressive and manic/hypomanic states  Lithium reduces risk of relapse w/ clear protective effects w/ respect to manic episodes  Side effects: nausea, dizziness, weight gain, and mild diarrhea  Li has narrow window of effectiveness (low doses ineffective, high doses toxic)  Other mood stabilizers have less of an effect of depressive symptoms and used conjointly with antidepressants STIMULANTS  Class of drugs most commonly used in treatment of children and adults with AD/HD  Short acting compounds with an onset of action within 30-60 minutes and peak clinical efficacy 1-5 hours after administration  Stimulants like Ritalin reduce hyperactive and impulsive, permitting child to sustain attention  70% response rate in the treatment of uncomplicated ADHD  Meta-analytic study on use of Ritalin for treatment of adult ADHD found effects comparable to results in the treatment of child and adolescent patients  Side effects are appetite suppression and sleep disturbance, and less frequently report mood disturbance, headaches, abdominal discomfort, and fatigue  Stimulants combined with psychological treatment should be the first-line treatment for severe ADHD in children and for moderate and severe ADHD in adults LIMITS ON EFFICACY  No class of drugs is efficacious for all people with a particular disorder, and iti s not possible to predict who will respond to a particular class of drugs  Medication does not necessarily enable the individual to learn new skills or to process information in a different way.  Medication may be helpful in symptom control, but without concomitant psychological interventions, the person may be prone to relapse and chronic disorder Psychotherapy: A Definition  Psychotherapy is defined as a process in which a professionally trained therapist systematically uses techniques derived from psychological principles to relieve another person’s psychological distress or to facilitate growth.  in Canada, the title psychotherapist is not licensed or restricted in any fashion; Theoretical Orientations  major schools of psychotherapy to be psychodynamic, cognitive-behavioural (including behavioural and cognitive approaches), humanistic-experiential, and integrative or eclectic  The current emphasis on identifying and disseminating treatments that work represents a shift in attention from theoretical debates toward a search to ensure that psychological interventions are helpful. So, instead of defending their own beliefs, psychologists focus on identifying what will help the patient. PSYCHODYNAMIC APPROACHES  Classic psychoanalysts rely heavily on five basic techniques: 1. Free association. The analyst requires the individual to say everything that comes to mind without censoring seemingly unimportant or embarrassing thoughts. The analyst helps the patient recognize unconscious motives and conflicts expressed in the spontaneous speech. 2. Dream interpretation. The analyst distinguishes between the manifest content of the dream (which is consciously remembered by the client) and the more important latent content (the unconscious ideas and impulses that have been disguised). 3. Interpretation. The analyst interprets what the client says or does. Slips of the tongue, forgetfulness, and the client’s behaviour are presumed to reveal unconscious impulses, defence mechanisms, or conflicts. First, the analyst interprets behaviour that the client is already on the verge of understanding. Later, the therapist interprets the unconscious conflicts that induce defence mechanisms. 4. Analysis of resistance. During the process of free association or dream interpretation, clients may become resistant—for example, being unwilling to discuss certain topics, missing or arriving late for appointments, joking during the session, or remaining silent. Resistance prevents painful or difficult thoughts from entering awareness; thus, therapists must determine the source of resistance if the client is to deal effectively with the problem. 5. Analysis of transference. The core of psychoanalytic therapy is transference, which occurs when the client responds to the therapist as he or she responded to significant figures from his or her childhood (generally the parents). Freud believed that individuals unconsciously re-experience repressed thoughts during transference, making it essential to the resolution of the client’s problems. By recognizing the transference relationship and remaining neutral, the therapist helps the client work through the conflict. The analyst is careful not to allow personal feelings, needs, or fears to interfere with the relationship with the client (counter-transference). Focus 17.1 Should Psychologists Prescribe Medication? Advocates of prescription privileges for psychologists argue that: 1. Many major mental disorders (such as schizophrenia) are best treated with medication. 2. It might be more cost-effective for psychologists to prescribe for their patients rather than referring patients to psychiatrists or physicians. 3. Underserved groups such as the elderly, the chronically mentally ill, and those living in rural areas would benefit from expanded opportunities to receive pharmaceutical treatment from mental health professionals. 4. Psychologists can be at least as competent as other health care professionals in prescribing medication for psychological disorders. Most psychoactive medications are prescribed by general practitioners whose training in mental health issues is limited to a few weeks of placement with a psychiatrist.  Physicians oppose citing importance of full medical training to understand the impact of psychoactive medication on other physical systems BRIEF PSYCHODYNAMIC PSYCHOTHERAPY  Freudian techniques in an active, flexible manner. Therapy tends to be short term: sessions occur twice a week rather than daily.  Goals are concrete, conversation replaces free association, therapists are empathic rather than emotionally detached, and interpretations focus on current life events rather than on childhood EGO ANALYSIS  Ego analysts, Karen Horney, Erik Erikson, Anna Freud, and Heinz Hartmann argued that Freudian analysis was too focused on the unconscious sexual and aggressive motivation  Believed that individuals are capable of controlling their own behaviour.  Ego analysts explore the ego rather than the id, help clients understand how they have relied on defence mechanisms to cope with conflicts ADLER’S INDIVIDUAL PSYCHOLOGY  Alfred Adler proposed that sexual and aggressive instincts are less important than the individual’s striving to overcome personal weakness.  Based on assumption that mental disorders consequence of deeply entrenched mistaken beliefs, which lead individuals to develop a maladaptive style of life that protects them from discovering their own imperfections.  Interpret dreams in terms of current behaviour, offer direct advice, and encourage new behaviours. INTERPERSONAL PSYCHODYNAMIC PSYCHOTHERAPY  Harry Stack Sullivan, the American psychiatrist who developed interpersonal psychodynamic psychotherapy believed that mental disorders resulted from maladaptive early interactions between child and parent.  A variation of brief psychodynamic therapy and emphasizes the interactions between the client and his or her social environment.  Therapists provide feedback to help the client understand how his or her inter-personal styles (such as hostility or dependence) are perpetuating or provoking conflicts. o Helps the client learn to interact with others in more flexible and positive ways and must be careful not to reinforce the client’s maladaptive behaviours. TIME-LIMITED DYNAMIC PSYCHOTHERAPY  tend to be briefer and to involve the client in face-to-face contact with the therapist  Helps identify patterns of interaction with others that strengthen unhelpful thoughts about self and others.  Importance of the therapeutic alliance quality of the relationship between therapist and client is recognized to be a predictor of therapy outcome.  greater emphasis on interpersonal processes than did early psychoanalytic formulations HUMANISTIC-EXPERIENTAL APPROACHES  humanistic and experiential approaches focus on the person’s subjective experience, giving particular attention to emotional aspects of experience  Humanistic-experiential approaches place emphasis on the person’s current experience rather than on the past.  value the individual’s free will and encourage the client to take responsibility for personal choices  A major contribution of the humanistic approaches has been the emphasis on the human qualities of the therapist.  therapists working with different approaches are more effective when their clients feel that they are genuine, that they make efforts to understand their experience, and that they accept them despite their problems CLIENT-CENTRED THERAPY  Carl Rogers developed client-centred therapy in the 1940s as an alternative to psychoanalysis.  Emphasizes the warmth and permissiveness of the therapist and the tolerant climate in which the feelings of the client can be freely expressed.  Psychological problems arise when personal growth is stunted by judgments imposed by others  Creates conditions of worth in which the client believes that he or she must meet the standards of others in order to be a worthwhile person.  Therapist qualities that facilitate the client’s growth: genuineness, empathy, and “unconditional positive regard.”  Therapist strives to provide an environment in which the client feels accepted.  Theorized that self-acceptance follows, and this in turn leads to self-knowledge and dissipation of bad feelings.  Clients are not diagnosed, evaluated, or given advice; rather, they are valued as unique individuals. EXISTENTIAL THERAPY  Inspired by the work of existential philosophers such as Sartre and Kierkegaard.  Focuses on the importance of the human situation as perceived by the individual, with the ultimate goal of making the client more aware of his or her own potential for growth and capacity for making choices.  Does not follow any particular procedures but emphasize the uniqueness of each individual.  Therapist helps the client relate authentically to others through the therapeutic encounter.  share themselves, their feelings, and their values with the client  Examines the lack of meaning in a person’s life, and is assumed to work best with those who are having conflicts regarding their existence, or those with anxiety or personality disorders rather than psychoses. GESTALT THERAPY  Frederich (Fritz) Perls  individuals have a distorted awareness of genuine feelings that leads to impairments in personal growth and behavioural problems  therapists help clients become aware of feelings and needs that have been ignored or distorted  clients must integrate both inner feelings and external environments EMOTION-FOCUSSED THERAPY  Les Greenberg  Client enters into an empathic relationship with a therapist who is directive and responsive to his/her experience  Address common psychological problems such as depression, trauma, and marital distress by enhancing and then focusing on client’s emotional reactions COGNITIVE-BEHAVIOURAL APPROACHES  Term behaviour therapy first used in the 1950s to describe operant conditioning treatment for psychotic patients  Emphasize problem behaviours are learned behaviours  Faulty learning can be reversed through the application of learning principles  Focus primarily on present thoughts and behaviours as opposed to childhood history  Behavioural interventions focus on specific targets, such as dealing with social phobia, reducing the frequency of bulimic symptoms, +
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