Class 24: Therapies

Trephination

Evidence in Neolithic man, with spherical holes cut in ancient skulls, that healed

• in Ancient Greece (Hippocrates) to release “humors” or bodily fluids related to head injury. Later epilepsy. By 15th century, for melancholy

• Thomas Willis (famed 16th century neuroanatomist who coined the term “neurology” and named the striatum) advocated trephination for melancholy

Early “Therapies“ for Psychological Disorders

In 1897, general paresis was discovered to be a consequence of syphilis

• General paresis caused by syphilis accounted for about 25% of psychiatric inpatients at the time

• Syphilis discovery provided proof that psychological disorders could have medical causes paved the way for a biomedical approach to psychological disorders

Sigmund Freud’s “talking cure” around the same time because the first formal therapy for psychological disorders that drew attention to environmental and social factors in mental illness

Classical Psychoanalysis

• Freud believed that emotionally charged memories and conflicts were repressed (pushed out of consciousness) i.e. “motivated forgetting”

• Emotions around repressed memories were expressed in symptoms like aggression, anxiety, depression and in physical symptoms like “psychogenic pain”

• The goal of psychoanalysis was to bring unconscious conflicts and emotions into consciousness where they could be dealt with rationally

Free association

A method in which the patient says anything that comes to mind, no matter how apparently trivial, embarrassing, or disagreeable

Resistance

A patient’s self-censorship or avoidance of certain topics

Transference

Interpreting how the patient acted toward the therapist, considered to be a re-enactment of significant relationships (Emotional re-education)

Slips of the tongue

Mis-speaking provided insight into true beliefs

Interpretation of dreams

Considered the content of dreams to be an expression of the unconscious that could be interpreted thru interpreting symbols which he thought of as the language of dreams

Psychodynamic approaches

Contemporary psychodynamic therapies have been modified from psychoanalysis

• less frequent than Freud’s (daily) sessions and lasts months to a year, not years

• Meet face-to-face, rather than our of sight while the patient reclined on a couch

• Conscious thoughts receive as much consideration as unconscious conflicts

• Includes focus on improving current responses to stressors to improve functioning and relieve symptoms

Psychodynamic approaches: interpersonal therapy (IPT)

Assumption is that mood is tied to relationship quality and life events

• targets problems like life transitions, complicated grief, interpersonal disputes, and interpersonal deficits

• Time limited (usually 12 - 16 weeks)

• First weeks are spent collecting information, creating an “interpersonal inventory” of relationships, and choosing a focus for therapy

• Subsequent sessions consider actions that could improve the situation

  • Identifying conflict in relationships

  • Role-playing difficult conversations

  • Identifying challenges related to life transitions and building social support networks to help

  • Patient works on solutions between sessions

Humanistic approaches

Focus on self-actualization, growth he present and the future

Assume shall humans are oriented toward growth, the search for meaning and self-actualization

Therapy focuses on the present and the future

Helps patients see themselves as agents in their lives, and take productive action and responsibility

• regards psychoanalysis as too concerned with basic urged like sex and aggression, and too focused on the past

Motivational interviewing

A brief, client-centered therapy designed to address specific problematic behaviors such as alcohol or drug use

• draws out the client’s goals, reduce ambivalence, and clarify gaps between how client says they want to live and how they are living

• Used in Serious Mental Illness (e.g. schizophrenia), before beginning an intervention to help the person identify with the purpose and goals and autonomously choose to participate

Client-centered therapy (person -centered therapy)

The therapist’s genuineness, unconditional positive regard, and empathic understanding are crucial to therapeutic success (“Rogerian therapy”)

• seeks to help clients accept themselves as they are without pretense or self-imposed limits

Behavioral Approaches

Exposure techniques

• systematic desensitization

• In vivo exposure

• Exposure and response prevention

Exposure techniques

Remove the anxiety connected to a feared stimulus through repeated approach toward the feared stimulus

Systematic desensitization

Gradually increasing encounters with the feared stimulus with periods of relaxation between

In vivo exposure

Patient is exposed to the phobic stimulus in the real world or through interactive computer programs (VR)

Exposure and Response Prevention

Behavioral treatment of OCD where the patient delays performing the compulsion to relive anxiety

Rational Emotive Therapy (cognitive approach)

Therapist challenges the patient’s irrational beliefs

• pioneered by Albert Ellis

• Assumes that beliefs (B) link activating events (A) and consequences (C)

• If a client’s beliefs are irrational, they will lead to negative consequences

  • The therapist disputes the irrational beliefs and offers more effective substitutes

Cognitive Therapy

An approach that aims to change patient’s habitual modes of dysfunctional thinking about themselves, their situation, and their future

• developed by Aaron Beck

Negative cognitive triad

Three types of dysfunctional beliefs related to oneself, their situation world, and the future

• unhelpful assumptions (core beliefs): “I am inferior”, “My worth depends on what others think of me”

• Critical incident later in life: relationship breakup

• Negative automatic thoughts or cognitive distortions: “It’s all my fault”, “I’ll be alone forever”, “I’m stupid”, “something is wrong with me”

Cognitive restructuring

A set of cognitive therapy techniques for changing a person’s maladaptive beliefs or interpretations through persuasion and confrontation

Cognitive-Behavioral Therapy (CBT)

A hybrid approach focused on changing the patient’s habitual interpretations of the world and behaviors by combining cognitive and behavioral approaches to therapy

• General principles of CBT

  • Present-focused

  • Concerned with identifying and solving problems that clients wish to address

  • Sessions are highly structured, with assigned homework

  • Goals are transparent, set collaboratively, and progress is openly discussed

Acceptance and commitment therapy

Aims to help clients achieve greater awareness and acceptance of thoughts and feelings; de-fuse from thoughts; emphasizes pursuing valued goals despite unwanted thoughts and feelings

Mindfulness-based stress reduction

Draws from southeast Asian meditative traditions to teach clients to be fully present by observing their thoughts, feelings and sensations non-judgmentally. Practices controlled breathing

What is eclecticism?

Approach to treatment that weaves together multiple types of therapy

Dialectical behavior therapy

Now a single therapy, but brought together different approaches to treat Borderline Personality Disorder

• “dialectic” — a dialogue about two different points of view to arrive at truth through reasoned argument

• The relationship between things defines things (no single cause/effect, no blame, ficus on acceptance and adaptation)

• Holding two opposite ideas simultaneously is the foundation of change (e.g. accepting the present and working toward chnage

• moves away from all-or-nothing, either/or thinking (“I am angry AND I love you” “I accept who I am AND I want to change”

Also has a group component to allow people to practice interpersonal skills like communication in a safe space, develop community and reduce shame

Cognitive-Behavioral

Clarifying link among thoughts, feelings, and behaviors, and identifying and changing unhelpful thought patterns

Psychodynamic

Interprets transference and resistance, and considers the influence of the past on current relationships

Humanistic

Focus on validation, self-acceptance and personal growth

Matched-Treatment Eclecticism

The clinician selects the treatment approach based on the person’s complaints. Different approaches for different patients and more than one approach for a single patient

• Exposure and response prevention for OCD and CBT for maladaptive cognitions

• CBT and medication for depression

• CBT and Mindfulness-Based Stress Reduction for Generalized Anxiety Disorder

Challenging for clinician to stay up to date and expert in the practice of multiple treatment interventions

Group therapy

A form of therapy in which two or more patients meet with one or more therapists at time

• Advantages over one-on-one therapy:

  • More clients can be accommodated by a limited number of therapists

  • Allows therapists to observe and treat problems that emerge in group settings (interpersonal relations)

  • Patients can see problems more objectively in other people

  • A sense of group belonging, support, and encouragement

Self-help and Support Groups

Individuals with a particular type of problem gather to share information, advice, support

• e.g. Alcoholics Anonymous

Therapeutic Efficacy and Common Factors

Different forms of therapy each inspire in clients new ways of thinking about difficulties they are having, provide strategies to overcome difficulties, and support on the journey their role in repetitive interpersonal conflicts

• conflicting goals and see a path towards reconciling them

• What triggers their anxiety and how to develop confidence to interact normally

• The powerful role of automatic thoughts

• That psychological disorders, like medical disorders, are treatable and not shameful problems

Therapeutic alliance

The relationship between therapist and patient that helps ,any patients feel hopeful and supported

• most important predictor of therapy efficacy, even in med response

psychopharmacology: Typical Antipsychotics

antipsychotic medications that blocks the transmission of dopamine, by binding to the D2 dopamine receptor

• reduce the positive symptoms of schizophrenia like thought disorder and hallucinations

• Less effective at treating negative symptoms of schizophrenia, like flat affect and the inability to feel pleasure

Side effects:

• common: fatigue, weight gain, restlessness, sexual dysfunction, amenorrhea, dry mouth, hyperprolactinemia (can disrupt menstruation, cause milk discharge from nipples, cause males to grow breasts), falls From sudden drops in blood pressure, heart arrhythmias

• Long-term: Tardive dyskinesia (involuntary movements of face and younger)

Clozapine: the Original Atypical

Antipsychotic medication that blocks the transmission of dopamine, but unbinds quickly, and also binds to alpha-adrenergic receptors and serotonergic receptors

• reduce the positive symptoms of schizophrenia-like thought disorder and hallucinations

• Better than typical antipsychotics at treating negative symptoms, like flat affect and the inability to feel pleasure

• Reduces suicidality

Side effects:

• Greater than typicals: weight gain, hyper-salivation, fatigue, diabetes,, agranulocytosis (requires blood monitoring)

• Does not cause hyperprolactinemia and its complications

• Similar to typicals in restlessness, sexual dysfunction, falls from sudden drops in blood pressure, heart arrhythmias

Long-term: (less than typicals but present) Tardive dyskinesia

Antidepressants

Early antidepressants fell into two major classes:

• monoamine oxidase (MAO) inhibitors and Tricyclics

• Both increased synaptic levels of norepinephrine

• Both had potentially fatal side effect profiles

Selective serotonin reuptake inhibitor (SSRI)

Increases synaptic serotonin levels (e.g. Prozac, Zoloft, Celexa)

• fewer side effects than earlier treatments

• Side effects: headache, nausea, insomnia, bad dreams, sexual dysfunction

• Must be slowly down-titrated to discontinue

Selective serotonin reuptake inhibitor (SNRI)

Increases synaptic serotonin and norepinephrine levels (e.g. Effexor)

• Less used because more dry mouth, sweating and can increase anxiety

Limitations of antidepressants

• one month to take effect

• Uncertainty about how much benefit can be attributed to placebo effects

  • Placebo effects: the influence of a patient’s beliefs and expectations In bringing about a cure

• Necessary trial and error period of prescription to determine benefits and side-effects of different drugs for individuals

• Potential for reduced benefit after prolonged use slide effects: weight gain, insomnia, loss of sexual desire

Mood stabilizer

A medication that treats manic, mixed, or depressive states . Use to treat bipolar disorder

Lithium carbonate (the first mood stabilizer and still used today)

• more effective at reducing manic than depressive symptoms

• Works for 60-70% of people with bipolar disorder

• Side effects: weight gain, sedation, dry mouth, tremors

• Toxic at higher doses

Carbamazepine

Anti-seize med also used as a mood stabilizer

Anti anxiety Medications (Anxiolytic)

Benzodiazepines and Beta blockers

Benzodiazepines

Enhance the effect of GABA binding, hyperpolarizing the cell (prevents from firing) (e.g. Xanax, Ativan, Valium)

• other agents that bind to GABA sites: barbiturates (sedative sand anti-seizure) and an aesthetics like propofol (both potentially fatal) and alcohol

Beta blockers

Blocks beta-adrenergic receptors (involved in fight or flight) so decrease physical symptoms of anxiety and prevents negative spiral. Used especially for situational anxiety (performance anxiety, social anxiety, flying phobia) ((e.g. propranolol (Inderal), atenolol). Also used in PTSD

Antianxiety Medications: Considerations

Benzodiazepines:

• Can be useful short-term. Not recommended for long-term use due to

  • High addictive potential

  • Dangerous interactions with alcohol

  • Risk to fetal development if patient is pregnant

  • Rebound effects

  • Does not address the cause of anxiety

Beta-blockers:

• can cause drowsiness, cold hands and feet, low blood pressure

Medication Treatment for ADHD

Stimulants: Methylphenidate, D-amphetamine

• Bind to the presynaptic dopamine transporter (DAT) and norepinephrine transporter (NET) to block reuptake of DA and NE into the presynaptic neuron

  • This increases synaptic levels of dopamine and norepinephrine transporter

Effects: improves ADHD symptoms in 70-80% children, 70& of adults

Discontinuation rates: high in transition from childhood to late adolescence. In adults, discontinuation rates range from 52-87%

• Reasons for discontinuation: mood changes, increased anxiety, irritability, personality changes, and perceived ineffectiveness

Costs and Benefits of Using Psychotropic

Psychotropic medications have provided profound benefits for many people

• Lifted people out of misery and allowed for more normal lives

• Allowed people to remain in communities and avoid being hospitalized

• Guesswork regarding dose and right medication

• Statistically effective medications still do not work in many people

• Adaptive response may not be learned so problem persists when meds stop

• Side effects can mean people want to discontinue, and then may relapse

• Some drugs cause rebound symptoms when discontinued, making them difficult to discontinue