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Chapter 15

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Dan Dolderman

Chapter 15: Treatment of Psychological Disorders Dennis was experiencing panic attacks (had to run to car and lie down while he was shopping with his fiancée) combined with agoraphobia, got treatment and was eventually able to go to places that he associated with panic attacks (like crowded malls)  No instant cures for mental disorders, need to be managed over time through treatment that alleviate symptoms so people can function in their daily lives How are Psychological Disorders Treated?  Most can be treated in more than one way but often one particular method is most successful for a specific disorder  2 categories of techniques to treat mental disorder: o Psychotherapy: the generic name given to formal psychological treatment, all forms involve interactions between practitioner and patient to help client understand his symptoms and problems and finding solutions o Biological Therapies: treatment based on medical approaches to illness and to disease, range from drugs to electrical stimulations of brain regions  Success may need client to continue treatment long-term  Recent focus on pairing with non-biological treatments o Psychopharmacology: the use of medications that affect brain or body functions  Knowing cause of a disorder doesn’t really mean you know how to treat it—autism is biological but non-biological treatment is most affective Psychotherapy is Based on Psychological Principles  One factor know to affect the outcome of therapy is the relationship between the therapist and the patient (a good relationship can foster an expectation of receiving help) Psychodynamic Therapy Focuses on Insight  Freud believed mental disorders were caused by past experiences o Psychoanalysis (had patient lie on couch while he say behind them so they gel t less inhibited by his presence) o Involved uncovering unconscious feelings and drives that he believed gave rise to maladaptive behaviours  Free Association—client would say whatever came to mind  Dream Analysis—therapist would interpret the meaning of client’s dreams  Insight: was the general goal; a patient’s understanding of his or her own psychological problems o Clients would be freed from unconscious influences and symptoms would disappear  Now known as psychodynamic therapy, has been controversial—expensive and time consuming, evidence shows that it has positive effects for borderline personality disorder but not much evidence for other mental disorders  New short term treatment which focuses on current relationships to treat depression, eating disorders and substance abuse Humanistic Therapies Focus on the Whole Person  Emphasizes personal experience and belief systems and the phenomenology of people  Client Centred Therapy: an empathic approach to therapy, it encourages personal growth through greater self-understanding, key part is making a comforting environment for clients to access their true feelings, accept the client through unconditional positive regard o Reflective Learning: therapist repeats the client’s concerns to help the person clarify his or her feelings o Motivational Interviewing: used of problem drinkers, uses a client based approach over a very short period  Currently used to establish a good therapeutic relationship Cognitive-Behavioural Therapy Targets-Thoughts and Behaviours  Most successful therapies involve changing people’s behaviour and cognition directly  Premise in behavioural therapy is that behaviour is learned and can be unlearned using the principles of classical and operant conditioning (rewards desired behaviours)  Social skills training—first start with modelling the therapist an rehearse it in therapy (learning to initiate convo) and later apply the behaviour  Cognitive Therapy: treatment based on the idea that distorted thought produce maladaptive emotions and behaviours  Cognitive Re-structuring: a therapy that strives to help patients recognize maladaptive thought patterns and replace them with ways of viewing the world that are more in tune with reality  Rationalemotive Therapy: therapist acts as a teacher who explains and demonstrates more adaptive ways of thinking and behaving (think behaviours result from individuals’ belief systems)  Interpersonal Therapy: integrates insight therapy and cognitive therapy, focuses of relationship the client tries to avoid and helping clients express their emotions and explore interpersonal experiences  Cognitive Behavioural Therapy (CBT): a therapy that incorporates techniques given from behavioral therapy and cognitive therapy to correct faulty thinking and change maladaptive behaviours, one of the most effective especially for anxiety/mood disorders  Exposure: a behavioural therapy technique that involves repeated exposure to an anxiety-producing stimulus or situation, based on classical conditioning (when they avoid feared stimuli, they experience reductions in anxiety that reinforce avoidance) Group Therapy Build Social Support  Popular after WWII---too many people needed treatment  Can offer advantages over individual therapy (most obvious is cost, provides opportunity to improve social skills and learn from other people’s experiences  Some practitioners think 8 is the ideal number (I KNOW YOU’LL REMEMBER THAT!)  Can be organized around type of problem (sexual abuse) or type of client (kids), may be highly structured(cognitive-behavioural groups, effective in treating obsessive- compulsive disorders and bulimia) or not, people can join and leave at different times Family Therapy Focuses on the Family Context  Systems Approach: an individual is part of a bigger context and any change in individual behaviour will affect the whole system, each person in family has a role and affects other members  Families level of negative expressed emotions correspond to the relapse rate for patients with schizophrenia and relapse rates are highest if the client has a great deal of contact with the family o Seen across cultures but the patterns of expressed emotions that affect relapse are different (over-involvement may be fine in some cultures)  Relapse is more common in emotionally over-involved families in Japan than India  Expressed Emotions: a pattern of interactions that includes emotional over- involvement, critical comments and hostility toward a patient by family members Confession is good for the Spirit  Catharsis; describes the way certain messages evoke powerful emotional reactions and subsequent relief  Freud believed that uncovering unconscious material and talking about it would bring about catharsis and subsequent relief from symptoms  Just the act of telling someone your problems or writing about It over email can have healing powers; reduces blood pressure, muscle tension etc. can even have effect on immune function, improve memory/cognition and better performance in work  When people reveal highly emotional material they can go into a trance-like state Culture can affect the Therapeutic Process  Has multiple influences on how disorders are expressed, which people with mental disorders are likely to recover and people’s willingness to seek help  Psychotherapy is accepted to different extents in different cultures (Chinas has few therapists), had earthquake—lots of therapists rushed In but not many people showed up because of the stigma of not seeking help for depression, anger etc.  Indian government is seeing how mental disorders can be as debilitating as malaria, screen people but use words like strain and tension instead of anxiety (stigma)  Culture also affects how affective therapy is for various cultures and ethnic groups living in a country—can’t look at people of different gender, race and culture the same (experiences differ in multiple ways that have a cumulative effect on mental disorders, these differences must be addressed in therapy) Medication is Affective for Certain Disorders  Psychotropic Medications: drugs that affect mental processes, act by changing brain neurochemistry-inhibit action potentials or by altering synaptic transmissions or increase the action of particular neurotransmitters  Anti-anxiety drugs(tranquilizers):a class of psychotropic medications used to treat anxiety—short term; increase the activity of GABA (inhibitory neurotransmitter) they are highly addictive so should be used sparingly—also makes you drowsy  Antidepressants: a class of psychotropic medications used to treat depression, monoamine oxidase is an enzyme that converts serotonin into another chemical form, MAO inhibitors therefore result in more serotonin available in the synapse o Tricyclic Antidepressants: inhibit the reuptake of certain neurotransmitters, resulting in more of each being available in the synapse o Selective Serotonin Reuptake Inhibitors (SSRI’S): Prozac, inhibit the reuptake of serotonin, sexual dysfunction is a side effect, also treat anxiety disorders  Antipsychotics(neuroleptics): a class of drugs used to treat schizophrenia and other disorders that involve psychosis, reduce delusions and hallucinations; bind to dopamine receptors, thus blocking the effects of dopamine; tardive dyskinesia—involuntary twitching of muscles, not useful for treating the negative symptoms of schizophrenia such as social withdrawal, Clozapine is one of the newer ones—effects other receptors  Lithium and anti-consultants are the most effective treatment for bipolar disorder (don’t fit into category) Alternative Biological Treatments are used in Extreme Cases  Brain surgery, use of magnetic field s or electric stimulation, when none of ^ works, last resort—serious side effects  Trepanning—in the past to let out evil spirits (hole in skull)used in African and Pacific for insanity; Psychosurgery—areas of the frontal cortex were damaged, used to treat things like depression and anxiety disorders (prefrontal lobotomy)—patients became very “flat” and also impaired other important mental functions(abstract thought, planning and motivation) today brain surgery is used as a last resort Electroconvulsive Therapy (ECT)  Procedure to treat depression; it involves administering a strong electrical current to the patient’s brain using electrodes—produces a seizure, in the 50s/60s was commonly used to treat schizophrenia and depression, now used with anesthesia and muscle relaxants to confine the seizure to the brain, effective in treating severe depression Transcranial Magnetic Stimulation(TMS)  Powerful electric current produces a strong magnetic field that when rapidly switched on and off, induces an electrical current in the brain region directly below the coil— which interrupts neural brain functioning (inhibiting someone’s speech) o Single pulse TMS is short term while multiple pulses over extended time (Repeated TMS), the disruption can last beyond the period of direct stimulation, may be especially useful to treat depression Deep Brain Stimulation FIG 12.15  Surgically implanting electrodes deep within the brain and then using mild electricity to stimulate the at brain at an optimal frequency and intensity  Used to treat Parkinson’s Disease with success  Few side effects and low complication rate Therapies Not Supported by Scientific Evidence Can be Dangerous  Some treatments that are widely believed to be effective are actually counter- productive: o Encourage people to describe their experiences after earthquake; using hypnosis to uncover painful memories o Those who describe experiences are more likely to develop post-traumatic stress disorder and hypnosis can produce false disorders  Girl died in blanket trying to “re-create her own birth”—fucked up shit What are the Most Affective Treatments  Highly effective treatments for anxiety disorders, mood disorders and sexual dysfunction but not for alcoholism  People enter therapy during crisis, so usually they show improvements no matter what therapy they receive  Finding from medical studies often lead to dramatic changes in treatment practice (evidence based treatments)  Psychological treatment to distinguish between evidence based from the more generic psychotherapy, which refers to any type of therapy  Three features characterize psychological treatment: o Vary according to the particular mental disorder and the client’s symptoms o Techniques used in in these treatments have been developed in the lab by psychological scientists o No overall grand theory guides treatment; based on effectiveness and evidence Treatments that Focus on Behaviour and on Cognition Are Superior for Anxiety Disorders  Psychoanalytic theory did not prove useful for treating anxiety disorders  Cognitive-behavioural therapy works best, effects are long-term  Anxiety reducing drugs are also useful (but can have relapse---tranquilizers work for short-term but do little to alleviate the source of anxiety)  Antidepressant drugs (block reuptake of serotonin and norepinephrine) are effective but limited to period the drug is taken Specific Phobias Table 15.1  Characterized by the fear and avoidance of specific stimuli  Behavioural techniques work best; systematic desensitization therapy, the client first makes a fear hierarchy (a list of situation in which fear is aroused in ascending order), next step is relaxation training, in which the client learns to alternate muscular tension with muscular relaxation techniques (cognitive-behavioural techniques are the best)  Exposure therapy is usually next step, while the client is relaxed he is told to imagine scenarios that are more and more upsetting (relaxation response eventually gets rid of the fear response)  Exposure to the feared object rather than the relaxation that extinguishes the phobic response (can use virtual reality—standing close to edge of a cliff)  Cognitive-behavioural therapy can alter the way the brain processes the fear stimulus, psychotherapy is seen to effectively “re-wire” the brain and therefore that both psychotherapy and medication affect the underlying biology of mental disorders  Pharmological treatments include tranquilizers and SSRI’s might be useful Panic Disorder  Has multiple components of which require a different treatment approach o To break the learned association between the physical symptoms and the feeling of impending doom, cognitive-behavioural therapy can be effective  Most important is based on cognitive therapy; cognitive re=structuring addresses ways of reacting to the symptoms of a panic attack  Clients identify their fears, then estimate how many panic attacks they’ve had-exp.: o A client might say he fears having a heart attack during 90 percent of her panic attacks and fainting during 85%, therapist than points out that the actual rate of occurrence was zero---people don’t faint during panic attacks  Even if clients see the irrationality in their fears the still get panic attacks o Because of a conditioned response to the trigger (e.g. Shortness of breath), goal of therapy is to break the connection between the trigger symptom and the resulting panic (only done by exposure treatment)  Cognitive-behavioural—its better. therapy appears to be as effective as or more effective than medication, psychotherapy—less likely to relapse then those on meds Obsessive Compulsive Disorder  OCD is a combination or recurrent intrusive thoughts(obsessions) and behaviours that an individual feels compelled to perform over and over (compulsions)  Traditional anti-anxiety drugs are completely ineffective, SSRI’s are also ineffective  The drug of choice in treating obsessive compulsive disorder is the potent serotonin reuptake inhibitor clomipramine (not a true SSRI—it blocks other neurotransmitters as well)  Cognitive behavioural therapy is also affective; two most important components of it are exposure and response prevention (client is directly exposed to stimuli that trigger compulsive behaviour but is prevented from engaging in this behaviour) goal is to break the conditioned link between a particular stimulus and a compulsive behaviour o Touch doorknob and not wash hands after  Some cognitive therapy is also useful, tell them most people get unwanted thoughts sometimes and it’s just normal  Exposure and response prevention technique proved superior to clomipramine (the drug choice for OCD)—both were better than a placebo  French man had obsessions about body parts and his compulsions included repetitive movements and dietary restrictions—DBS electrodes were implanted into his caudate and was very effective (relief from symptoms after 6 months of treatment) and improvement was seen over 2 years Many Effective Treatments are Available for Depression  No “best” way to treat depression Pharmacological Treatment  MAO inhibitors (iproniazid) can relieve depression but can be toxic because of their effects on various psychological systems, can get lethal elevation in blood pressure if they have wine or aged cheeses (have tyramine)—so it is reserved for people who don’t respond to anti-depressants  Tricyclics, another type of anti-depressant are very effective but have a lot of side effects such as drowsiness, weight gain, sweating, constipation and dry mouth  Development of Prozac; an SSRI which had none of the side effects that were seen in previous anti-depressants (does not affect histamine or acetylcholine) but it occasionally causes insomnia, headaches and sexual dysfunction  Bupropion is also used and doesn’t cause sexual dysfunction, unlike other SSRIs doesn’t treat OCS and panic disorder  60-70% of patients who take anti-depressants get better, placebos work a lot less better but those who use it show different brain activity than those who take anti-depressants o Patients positive expectancy may change brain activity  Trial and error when dealing with depressed patients (no best medication) o SSRI`s are first-line meds because they have the least side effects o Tricyclics might be the best for serious forms of depression  Those who stay on meds are a lot less likely to relapse than those who go on a placebo Cognitive-Behavioural Treatment of Depression FIG 15.15  Just as effective as biological treatment (used when people don’t want the side effects)  Cognitive perspective says people become depressed because of automatic, irrational thoughts and is the result of a triad of negative thoughts about oneself, the situation and the future  Goal is to help the person think more adaptively, there are some general principles: o Clients may be asked to recognize and record negative thoughts, then taught to view the same situation in way that isn’t dysfunctional  This therapy and meds are more effective when paired than if on their own
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