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TREATMENT METHODS

• Biological Approach (Drug (chemo) Therapy (anti anxiety /anti depressant and sedatives etc.) – ECT, Psychosurgery)

• Behavioural Approach (Aversion Therapy (counter conditioning), Systematic Desensitisation Therapy, Flooding & Token Economy)

• Psychodynamic Approach (Psychotherapy which may include: Dream Analysis, Projective Therapy – ink blot/pictures, Hypnosis, Free & Word Association)

• Cognitive Approach (Cognitive Behavioural Therapy – (CBT))

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• MOA: Removes brain tissue in an effort to change behaviour. (unsure of how!)

• Lobotomy (Moniz - Nobel Prize). – Calmed violent

patients, but produced lethargy & could destroy patients personalities (zombies).

– Side-effects also included: apathy, diminished intellectual powers, impaired judgements, coma, and even death

BiologicalTherapiesPsychosurgery

Antonio Egas Moniz

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Psychosurgery Summary

• Modern methods– Stereotactic neurosurgery (most

common method today)•much more accurate and do less

damage• Effectiveness

– Effective if performed precisely and on the appropriate patient i.e. severely depressed/suicidal as ‘last resort’

– Research shows: 33% high effectiveness, 33% moderate effect, 33% minimal or no effect

• Appropriateness– Only appropriate in severely depressed

or compulsive and suicidal patients who have not responded to other therapies.

– Only appropriate under BMA rules if have patients fully informed consent.

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Electroconvulsive Therapy (ECT)Video clip of ECT used in the past

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• Appropriate for treating severely depressed / suicidal patients. Sometimes given without their consent (if sectioned).

• Introduced during the late 1930s (Ugo Cerletti).

• Effective in lifting mood. Can stop suicidal thoughts rapidly – therefore can save lives.

• MOA: Increases norepinephrine (neurotransmitter that elevates mood) but not sure of MOA

• Perform about 20,000 per year in the U.K.

• May cause brain damage as….. • Substantial memory loss

(especially short term memory).

Electroconvulsive Therapy (ECT)

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• The guidelines for the administration of ECT. In general are:

– Patient is anesthetized.– Given muscle relaxant. – Shocked with about 100 volts

for a half to 3-4 seconds. – Patient experiences slight

seizures that last from 30 seconds to 1 minute.

– 3-6 treatments per week for several weeks (Though this protocol varies).

– Entire session (from prep. time to recovery time) takes between 1 to 2 hours.

– Effectiveness >70% improve

E.C.T.

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Drug (Chemo) Therapy• Most widely used Biomedical Therapy, as it is cheap,

relatively fast acting and ‘easy’ to give.• Appropriateness: treatment when taken responsibly,

and with the close supervision of a doctor. Drugs are given appropriate to a ‘specific’ symptom e.g. anti -(anxiety, depressive and psychotic drugs).

• Effectiveness: they are generally extremely effective at treating symptoms. (but many have side effects such as addiction). Drugs have liberated many people from mental hospitals – deinstitutionalization (a big +). Since the mid 50's, 70% of persons diagnosed with schizophrenia lived in mental hospitals - today, less than 5%.

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Types of drugs: • Anti Anxiety Drugs: Benzodiazepines (BZs)

– Reduce tension and anxiety. (downers) e.g. (Valium)– MOA : Enhance the action of neurotransmitter GABA

resulting in reduction in activity of brain – calming effect– Common Side Effects : drowsiness, fatigue, weight gain,

interactions with other medications.• Anti Depressive Drugs:

– Opposite of anti-anxiety drugs (uppers).– MOA: Increase of serotonin etc. (arousal-inducing

neurotransmitters). SSRI (e.g., Prozac) interferes with re-absorption of serotonin, creating high levels (brain arousal).

– Common Side Effects: dizziness, dry mouth, nausea.• Anti Psychotic Drugs: Neuroleptics

– Major Tranquilizers. – MOA: Decrease production of the neurotransmitter

Dopamine.– Relieves hallucinations, hostility.– Requires very close supervision by a

physician/psychiatrist.– Most popular: Thorazine. – Common Side Effects: Weight gain, constipation,

dizziness, drowsiness, dry mouth, nasal congestion

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Strengths & LimitationsStrengths of drug treatment:• Research (Kahn) showed that compared to a placebo,

BZs were more effective at reducing anxiety.• Drugs are generally extremely effective at treating

symptoms• Drugs are easy, relatively fast acting and cheap to use.

Weaknesses of drug treatment:• Addiction: BZs create a physiological dependence

creating marked withdrawal symptoms when stopped. Should be limited to 4 weeks use because of this.

• Side Effects: General (see individual drugs) In BZs they can be paradoxical (opposite to that expected) i.e. can cause aggressiveness. Also memory problems – storage difficulty.

• Sticking Plaster: Treats the symptoms not the problem so when drugs are stopped the symptoms return. So best paired with psychological therapies that address the problems.

• Drugs have liberated many people from mental hospitals – deinstitutionalization (a big +). Since the mid 50's, 70% of persons diagnosed with schizophrenia lived in mental hospitals - today, less than 5%.

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Psychodynamic Therapies

• Psychoanalysis – MOA: treatments concentrate on making the unconscious conscious (gaining INSIGHT – discovering the reasons for their problems). Then the mind can be cleansed of maladaptive thoughts and emotions (lancing the psychological boil – release of negative energy or CATHARSIS) This is accomplished by using interviews to ask about past, early experiences, parents, and siblings, inner fears and innate drives. It may include: Dream analysis – interpretation of symbolism in dreams. Projective tasks and/or Free and word association – saying whatever enters your head!

• Catharsis can then lead to healing (CLOSURE)

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Activity: Psychoanalytical Techniques

Have a go at some of the Psychoanalytical treatment techniques:

•Word Association

•Projective Task (Ink blots)

Be prepared to criticise each technique.

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Freud’s Dream Analysis

Male genitals, especially penis

Female genitals, especially vagina

Sexual intercourse

Parents

Umbrellas, knives, poles, swords, airplanes, guns, serpents, neckties

Boxes, caves, pockets, pouches, the mouth, jewel cases, ovens, closets

Climbing, swimming, flying, riding (a horse, an elevator, a roller coaster)

Kings, queens, emperors, empresses

Siblings Little animals

Latent Content Manifest Content of Dream

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• Bergin (1971) : Meta-analysis (Effectiveness) – Psychoanalysis produced an 73% success rate and was better than a placebo or

no treatment.• H.J. Eysenck (1952)

– Psychoanalysis is bad for you! • Sloane et al. (1975)

– Behaviour therapy and Psychoanalysis both had 80% improvement rate vs 48% control group

• Luborksy and Spence (1978) (Appropriateness) – Useful in the treatment of anxiety disorders, depression, sexual disorders, but

not schizophrenia– Useful with patients who are better educated

• Strengths & Limitations: – Unscientific, un-falsifiable, unqualified therapists, expensive and time

consuming, techniques require subjective interpretation and rely on the memory of the client, making them unreliable.

– Good for treating Sexual Problems.– Recognises the importance of early childhood in development of personality

and behaviour, so may aid prevention of mental illnesses.

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Psychotheapy Placebo No treatment

Appropriateness, Effectiveness, Evidence &

Strenths & Limitations

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1.Behavioural Therapies Based on Classical Conditioning

• MOA; Re-learning adaptive new behaviours to replace the maladaptive behaviour.

• Flooding or Implosion Therapy– Exposure to the feared stimulus = 70%

effective!

• Systematic desensitisation– Wolpe (1958)– Based on counter-conditioning (gradually

learning to re-associate the stimulus with a more positive response).

• Aversion therapy– Associate unwanted behaviour with a very

unpleasant unconditioned stimulus:-

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Behaviour Therapies• All these Learning techniques are used to

alter behaviours; these techniques include using:– Classical conditioning as in

•Aversion therapy… e.g.

•Systematic desensitization… e.g. Driving phobia?!!!!

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Systematic Desensitization

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Appropriateness & Effectiveness• Appropriate ONLY for behaviour that has been

learned. • Behaviour therapy is as effective as other forms of

therapy (Smith et al., 1980)• It is very effective with:

– Anxiety disorders (Ost, 1989)

– Obsessive-compulsive disorder (van Oppen et al., 1995)

– Specific phobia (Ost, 1989) ( i.e. flooding 70% effective)

• Not very effective with disorders with a genetic component, such as schizophrenia

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- Simplistic and Deterministic – limits all behaviour to simple cause and effect.

- Mechanical in its application – do this and this will happen- There are ethical questions relating to both research and

treatment methods. (Little Albert – Treating Gay Men)- Treats only the behaviour not the causes of the

behaviour.- Does not consider individual differences (blank slate?) –

we may all learn differently.+ Scientific approach with good supporting evidence &

easy to research.+ Therapies are successful for phobias, OCD and anxiety

disorders etc

? New learning or re-education is it always possible?

? What is unwanted behaviour? How is it defined and who

by? Used for punishment/social control (gay men)

Limitations / Criticisms

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COGNITIVE THERAPIES

• Cognitive Behavioural Therapy

• Cognitive Restructuring Therapy

• Rational Emotive Therapy• Stress Inoculation &

Hardiness Training.

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Cognitive Behavioural TherapyAppropriateness: Cognitive behavioural therapy (CBT) is used to help solve problems in people's lives, such as anxiety, depression, post-traumatic stress disorder (PTSD) or drug misuse. CBT was developed from two earlier types of psychotherapy:

•Cognitive therapy, designed to change people's thoughts, beliefs, attitudes and expectations. (i.e. Changing negative thoughts to positive) Includes Stress Innoculation and Hardiness training (both cognitive methods)•Behavioural therapy (designed to change how people acted/behaved).

American psychotherapist Aaron Beck developed CBT believing that the way we think about a situation affects how we act but also that our actions/behaviours can affect how we think and feel.

MOA: It is therefore necessary to change both the act of thinking (cognition) and behaviour at the same time. This is known as cognitive behavioural therapy. CBT says that your problems are often created by you. It is not the situation itself that is making you unhappy, but how you think about it and how you react to it. Video Clip (Trust me I am a Dr.)

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Effectiveness of CBT• CBT is often favoured over other

therapies because it aims to get rid of the problem not just the symptoms.

• Evans (1992) CBT is at least as good as drug therapy in preventing a relapse

• Keller (2001) combination of CBT and drug therapy more effective than either therapy alone

• Butler (2006) effectiveness depends on the disorder. When the problem is severe, a combination of drugs and CBT is best. E.g. Drugs may reduce disturbed thoughts of Schizophrenics allowing CBT to be used effectively.

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Strengths and Limitations

• Treatment very effective, especially when combined with drug therapy.

• Patient has a certain amount of control over their treatment and can use the techniques taught to them to deal with future problems and situations.

• Assumption is that patient is to ‘blame’ for their problems. This is the only therapy that assumes that the patient is at fault.

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The Therapy Game

• You will be put in groups of either Psychiatrists, Psychotherapists, Behavioural Therapists or Cognitive Therapists

• You are now the potential therapists of the following patients.

• Can you explain their abnormal behaviour?• Can you suggest an appropriate treatment?• You must stick strictly to the model/approach of your

particular group when answering these questions.• The team with the most appropriate explanation and

treatment will win the patient.• The team with the most patients wins the game!

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Patient No. 1

• You have 2 minutes to discuss the case with your fellow therapists and decide:

• What is the likely cause of the patients abnormal behaviour?

• Which treatment is the most suitable and why?

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Patient No. 2

• You have 2 minutes to discuss the case with your fellow therapists and decide:

• What is the likely cause of the patients abnormal behaviour?

• Which treatment is the most suitable and why?

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Patient No. 3

• You have 2 minutes to discuss the case with your fellow therapists and decide:

• What is the likely cause of the patients abnormal behaviour?

• Which treatment is the most suitable and why?

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Patient No. 4

• You have 2 minutes to discuss the case with your fellow therapists and decide:

• What is the likely cause of the patients abnormal behaviour?

• Which treatment is the most suitable and why?

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Patient No. 5

• You have 2 minutes to discuss the case with your fellow therapists and decide:

• What is the likely cause of the patients abnormal behaviour?

• Which treatment is the most suitable and why?

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The End

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Key Term: Abnormality• Behaviour that is considered to deviate from

the norm (statistical or social), or ideal mental health. It is dysfunctional because it is harmful or causes distress to the individual or others and so is considered to be a failure to function adequately. Abnormality is characterised by the fact that it is an undesirable state that causes severe impairment in the personal and social functioning of the individual, and often causes the person great anguish depending on how much insight they have into their illness

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Key Term: Anorexia nervosa• An eating disorder characterised by the

individual being severely underweight; 85% or less than expected for size and height. There is also anxiety, as the anorexic has an intense fear of becoming fat and a distorted body image. The individual does not have an accurate perception of their body size, seeing themselves as “normal”, when they are in fact significantly underweight, and they may minimise the dangers of being severely underweight

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Key Term: Bulimia nervosa• An eating disorder in which excessive (binge)

eating is followed by compensatory behaviour such as self-induced vomiting or misuse of laxatives. It is often experienced as an unbreakable cycle where the bulimic impulsively overeats and then has to purge to reduce anxiety and feelings of guilt about the amount of food consumed, which can be thousands of calories at a time. This disorder is not associated with excessive weight loss

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Key Term: Cultural relativism

• The view that one cannot judge behaviour properly unless it is viewed in the context from which it originates. This is because different cultures have different constructions of behaviour and so interpretations of behaviour may differ across cultures. A lack of cultural relativism can lead to ethnocentrism, where only the perspective of one’s own culture is taken

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Key Term: Deviation from ideal mental health • Deviation from optimal psychological well-

being (a state of contentment that we all strive to achieve). Deviation is characterised by a lack of positive self-attitudes, personal growth, autonomy, accurate view of reality, environmental mastery, and resistance to stress; all of which prevent the individual from accessing their potential, which is known as self-actualisation

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Key Term: Eating disorder • A dysfunctional relationship with food. The

dysfunction may be gross under-eating (anorexia), binge–purging (bulimia), over-eating (obesity), or healthy eating (orthorexia). These disorders may be characterised by faulty cognition and emotional responses to food, maladaptive conditioning, dysfunctional family relationships, early childhood conflicts, or a biological and genetic basis, but the nature and expression of eating disorders show great individual variation

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Key Term: Statistical infrequency/deviation from

statistical norms • Behaviours that are statistically rare or

deviate from the average/statistical norm as illustrated by the normal distribution curve, are classed as abnormal. Thus, any behaviour that is atypical of the majority would be statistically infrequent, and so abnormal (e.g., schizophrenia is suffered by 1 in 100 people and so is statistically rare)

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Factors Important to Mental Health

The factors that drive or motivate

individuals, according to

Maslow (1954)