Treatment of Disorders - Psych 102

What are the two families of treatment for clinical disorders?

• biomedical treatment: directly alter the functioning of the brain

• psychotherapy: done through an interaction with a psychotherapist aiming to provide support and/or relief from the problem

How do treatments differ in how they aim to help the client?

• direct intervention: address the cause to hopefully curing the disorder

• symptom support: reduce impairment of symptoms, but not the underlying cause

• insight: help patient learn about likely causes of disorder and decide how to deal with them

What are the problems with measuring treatment effectiveness?

• self report is unreliable

• the worst symptoms often go on their own

• placebo effects

• nocebo effects

What is placebo?

• an inert substance or procedure that is applied with the expectation that a healing response will be produced

What is nocebo?

• incorrect expectations about illness progression or treatment outcome make our symptoms worse (e.g., through stress)

What is efficacy?

• how well the treatment works in ideal conditions

What is effectiveness

• how well the treatment works in real-life conditions

Why is efficacy always higher than effectiveness?

• treatment might be prohibitively expensive

• treatment might produce severe side-effects

• treatment might be stigmatized

• treatment may produce nocebo effects

What is treatment outcome research/ randomized control trial (RCT)

• the “gold standard” experiment assessing the efficacy of an intervention; frequently done in medicine and clinical psychology to “test” treatment

What is inactive control?

• measures efficacy in comparison to doing nothing

• measures degree of natural improvement

• gives measure of patient bias for assessing pre-vs. post-symptoms

What is active control?

• measures efficacy in companion to doing something

• measures placebo and nocebo effects

What are biomedical approaches?

• treatments aimed at directly altering the functioning of the brain through drugs, stimulation, surgery

What type of approach are drugs and what is their mechanism?

• type: biomedical

• mechanism: direct intervention or symptom alleviation

What is the effectiveness of drugs?

• high; generally cheap and easy to administer with few side-effects

What are drugs used for?

• most clinical disorders, but especially anxiety, depressive, bipolar, schizophrenia, and neurodevelopment

What does serotonin do?

• primarily related to feelings of well-being, appetite, and sleep

What does dopamine do?

• primarily related to increasing activity in various brain regions, especially those related to reward and pleasurable feelings

What does GABA do?

• primarily related to inhibiting neuronal activity (more GABA = less activity)

What does norepinephrine do?

• primarily related to increasing arousal and sense of alertness, especially during the stress response

What are antipsychotics?

• drugs primarily used to treat psychotic conditions

What are the two major types of antipsychotic drugs?

• conventional/typical: exclusively block dopamine receptors, reducing the effects of dopamine in the brain. good for positive symptoms

• atypical: block activity of both serotonin and dopamine. fewer side-effects and helps with some negative symptoms

What are antipsychotics used for?

• schizophrenia, bipolar, treatment-resistant depression

How effective are anti-psychotics?

• the most effective treatment available for schizophrenia (especially positive symptoms)

What are the limitations of antipsychotics?

• significant side-effects and not always as good for negative symptoms

What are the side-effects of antipsychotics?

• weight-gain, involuntary muscle movements (dykinesia), diabetes, potential for some serious drug interactions

What are anxiolytics/anti-anxiety drugs?

• drugs used to treat anxiety; their popularity has been decreasing due to tendency for abuse and adverse interactions

What are the three major types of anxiolytics/anti-anxiety drugs?

• benzodiazepines: drugs that increase GABA; most commonly administered and most effective anxiolytic

• beta blockers: drugs that block norepinephrine, controlling muscle tension, blood pressure, and heart rate

• buspirone: drug that increases serotonin levels and is especially used for GAD and for anxiety with comorbid depression

What are anxiolytics drugs used for?

• anxiety (general and specific), sleep disorders, PTSD, OCD

What is the effectiveness of anxiolytics drugs?

• very high for most, but prescribed less than before

What are the limitations of anxiolytics drugs?

• only alleviates symptoms, builds strong drug-tolerance

What are the side-effects of anxiolytics drugs?

• withdrawal after tolerance, drowsiness, issues with motor coordination, potentially drug and chemical interactions (especially benzodiazepines)

What are antidepressants?

• medication used to treat depression, anxiety, and several other disorders; most commonly prescribed psychoactive medication

What are the three-major types of antidepressants?

• selective serotonin reuptake inhibitors (SSRIs): drugs that increase the amount of serotonin in the brain; historically the most popular anti-depressants

• bupropion: increases norepinephrine and dopamine, and has fewer side-effects than SSRIs; also used for smoking cessation

• serotonin-norepinephrine reuptake inhibitors (SNRIs): increase both serotonin and norepinephrine; rapidly increasing in popularity

What are antidepressants used for?

• depression, anxiety, addiction, PTSD, OCD

What is the effectiveness of antidepressants?

• very high after an initial delay period

What are the limitations of antidepressants?

• take time to start working (usually 1-3 months); require increasing dosage or change over time

What are the side-effects of antidepressants?

• very few for modern antidepressants — weight gain, reduced sexual desire, and (rarely) serotonin toxicity

What are mood stabilizers?

• drugs used to treat bipolar disorder that attempt to decrease the severity of depressive and manic episodes

What are the two major types of mood stabilizers?

• mineral salts/lithium: decrease epinephrine and increase serotonin, thus helping with both mania and depression; most commonly administered

• anticonvulsant: increase GABA and norepinephrine and especially help during manic episodes; also used to help prevent seizures in epileptic patients

What are mood stabilizers used for?

• bipolar disorder

What is the effectiveness of mood stabilizers?

• high in correct does for many patients, but doesn’t work universally

What are the limitations of mood stabilizers?

• individual differences requiring frequent visits to psychiatrist to adjust dose; required does can also change over time

What are the side-effects of mood stabilizers?

• can cause kidney and thyroid damage if dose is wrong, drowsiness, muscle weakness

What are psychostimulants?

• drugs used to treat attentional disorders; selectively relase norepinephrine, serotonin, and dopamine, boosting attention, wakefulness, and persistence

• unlike other psychoactive drugs, psychostimulants are frequently abused, and overdoses can be fatal

• there is continued debate over whether psychostimulants should be allowed for people not suffering from attention problems to generally boost performance

What are psychostimulants used for?

• ADHD, depression, eating disorders

How effective are psychostimulants?

• very high, though likely overprescribed

What are the limitations of psychostimulants?

• tolerance build-up; addictive, especially with recreational use

What are the side-effetcs of psychostimulants?

• insomnia, irritability, weight-loss drowsiness, decreased inhibitory control in high doses

What is psychotherapy?

• treatments done through an interaction with a professional psychotherapist

What are the two families of psychotherapy?

• insight-focused therapies: help client gain insight into the cause of their disorder, hopefully to address the cause afterwards

• intervention-focused therapies: help client change their thinking and behaving to help them cope with symptoms and/or directly address the cause of the disorder

What is psychoanalysis/psychodynamic therapy?

• therapy based on freudian principles of identifying and resolving unconscious conflicts

  • type: insight psychotherapy

  • mechanism: reveal unconscious causes of disorder then relive them through personality change

  • effectiveness: mixed - works for some high-functioning clients, but generally dispreferred to other therapies

  • used for: depression, anxiety, and personality disorders

What are the unique features of psychodynamic therapy?

• interpretation: the client doesn’t understand the cause of their problems, so the therapist must help reveal it to them

• transference: the client projects their unconscious desires and defense mechanisms onto the therapist, who analyze them

• removing interference: the client must be distraction free

• long time: on average, takes 2 years and requires meeting with the therapist multiple times a week

What is the focus in psychodynamic therapy?

• finding things that the client doesn’t want to talk about

• early childhood experiences and attachments (i.e., past, not present)

• possible sources of trauma (conscious and unconscious)

• talking about fantasies, dreams, hopes, and fears

• reading “between the lines” in what the client is saying, and building a narrative for what is really going on

What are the psychodynamic techniques?

• unstructured talk: the client and the therapist talk back-and-fort to reveal patterns of thoughts, but there is no pre-determined topic

• free association: client to freely generates ideas as they come to mind

• dream analysis: therapist analyzes dream journal clients are asked to keep

• resistance: clients becoming upset, refusing to discuss things, or even walking out of therapy are seen as evidence of defense mechanisms, which usually means the therapy is on the right track

What do psychoanalysts believe about effectiveness

• that effectiveness can not be measured

How effective is psychodynamic therapy?

• good for some clients: high-functioning and can come into treatment very frequently and achieve insight

• good for some disorders: especially panic disorder and borderline personality disorder

• good for some goals: if insight and a long-term relationship with a professional is desired psychoanalysis provides good outcome

What is person-centered therapy (PCT)?

• a humanistic therapy in which the therapist acts as a mirror through which the client reaches their own insight and becomes their “authentic self”

  • type: insight psychology

  • mechanism: by focusing on empathy and radical acceptance, clients accept themselves and find their own ways of dealing with their problems

  • effectiveness: good for high-functioning people seeking insight

  • used for: primarily for depression, anxiety, and addictions

What are the unique features of person-centered therapy?

• opposite of psychodynamic therapy:

  • insight comes form patient, not from therapist

  • the therapist is genuinely themselves, self-reports their own experiences, and act as a model for the client

  • emphasis is on open communication, empaathy, total acceptance

What are the techniques of person-centered therapy?

• unconditional positive regard: an approach in therapy where the therapist accepts, cares for, and seeks to understand the client no mater what they say or do

• active listening/mirroring: empathic listening in which the therapist echoes, restates, and clarifies what the patient said, but does not add their own interpretation

• motivational interviewing: the therapist restates noticed discrepancies in what the client is saying, doing, or believing, and asks them for clarification, but does not ask them to change

What is the evidence for the effectiveness of person-centered therapy?

• self-esteem and openness to experience: PCT increases the patient’s self-esteem and openness, which can especially help in cases of depression and anxiety

• long term: the effects are long-term for people who stick with it

• for high functioning patients

What is the first wave of intervention-based therapies?

• behavioural therapy: replacing automatic maladaptive behaviours with adaptive ones

What is the second wave of intervention-based therapies?

• cognitive therapy: replacing automatic maladaptive throughs (cognitive distortions) with adaptive ones

What is the third wave of intervention-based therapies?

• acceptance based: focus on flexibility, acceptance of thoughts, and patient/client values

What is cognitive/behavioural therapy (CBT)?

• therapist teaches skills to change client’s maladaptive automatic behaviours and cognitive distortions and replace them with more psotive ones

  • type: intervention-based psychotherapy

  • mechanism: change automatic thoughts and behaviours that are causing disorder or aggravating symptoms

  • effectiveness: when combined with medication, the most effective type of psychotherapy for most disorders

  • used: for almost everything

What are the unique features of CBT?

1. strongly informed by scientific research in psycholoy

2. client is taught about basic principles of psychology (psychoeducation)

3. teaching skills, not trying to find origins or narrative of disorder

4. client spends time doing homework to practice skills outside therapy

5. focused and short-term (usually 12 sessions over 3-6 months)

Wjay ios classical conditioning (behavioural)?

• automatic association of a stimulus with a psychical reaction by pairing them in time repeatedly

  • when used as treatment, client associates stimulus with either positive or negative emotions or bodily reactions

What is antabuse?

• a medication that inhibits your body’s ability to metabolize alcohol and makes you quickly nauseous after drinking

What is operant conditioning (behavioural)?

• association of stimulus with outcome through reward and punishment

  • in treatment, we choose a positive behaviour and reward the client whenever they do it (punishment is rare)

  • token economy: clients are given “tokens” (e.g., money) for desired behaviour that can be exchanged for rewards

  • monetary punishment: asking the client to set aside a pool of money that the therapist can withhold whenever they engage in undesirable behaviour

What is exposure (behavioural)?

• confronting an emotion-arousing stimulus repeatedly, leading to a decrease in physiological response

What is a response prevention (behavioural)?

• the maladaptive coping strategy is prevented to show the participant that nothing bad will happen if they resist the behaviour

What is cognitive restructuring (cognitive)?

• a broad range of techniques used to challenge, clarify, and remove automatic negative thoughts and beliefs

What is an example of cognitive restructuring (cognitive)?

• socratic questioning: the client is asked questions like:

  • to clarify thoughts (e.g., “Why do you say that?”)

  • to give evidence for a claim ("e.g., “What supports that?”)

  • to predict consequences (e.g., “How does this affect that?”)

  • to question the question (e.g., “Why was that question important?”)

What are thought journals (cognitive)?

• client records thoughts and associations outside of therapy as homework, and is taught to question the distorted ones

What is dialectical behavioural therapy (DBT)?

• teaching emotional regulation skills, accepting one’s thoughts and not identifying with them, and building self-compassion through mindfulness meditation

  • type: intervention-based psychotherapy

  • mechanism: teach client that their thoughts and emotions do not define them, and how to better manage them

  • effectiveness: still emerging, but rapidly gaining research support and growing in popularity

  • used for: BPD, self-harm and suicide, PTSD, depression, eating disorders

What are the unique features of DBT?

• DBT techniques are more hands-on training than other forms of therapy

  • frequent meetings: early DBT sessions occur around twice a week, and the course of therapy is up to 12 months

  • group/class settings: frequently administered in group settings; clients usually for this 2h/week

  • in-vivo coaching: the therapist is often available by phone or online to give live in-the-moment coaching as emergencies arise. clients usually do this for 1h/week

What are the DBT techniques?

• mindfulness meditation: to help the client recognize that their emotions and thoughts often come up with control, and to teach them to not attempt to control them but to accept them instead

• distress tolerance: learning to accept distress and not adopt maladaptive coping strategies

• interpersonal effectiveness: learning when and how to ask for help while maintaining good relationships with others

• emotional regulation: learn to better manage emotions of all types so they do not lead to automatic negative behaviours and thoughts

What is the effectiveness of DBT?

• it is considered the best-available treatment aviable for BPD

• DBT has a significant effect in reducing non-suicidal self harm behaviours

• evidence for other disorders is more limited, but emerging, and DBT-inspired group-therapy is becoming a popular model for clinical disorders where emotional distress is the most severe symptom

what is couples/ family therapy?

• Definition: This form of therapy involves helping individuals or groups within a relationship (such as romantic partners or family members) to improve communication, resolve conflicts, and enhance understanding. It can address issues like marital problems, parenting concerns, or family dynamics.

• Focus: It often focuses on improving relationship dynamics, understanding patterns of behavior, resolving interpersonal conflicts, and strengthening emotional bonds. The therapist works with all parties involved to facilitate healthier interactions and problem-solving.

• Common Techniques: Communication training, conflict resolution, behavioral interventions, and family systems theory.

What is group therapy?

• Definition: Group therapy involves one or more therapists working with a group of individuals to address specific psychological concerns. The group typically consists of 6-10 people, and the therapeutic environment provides shared experiences and support.

• Focus: The focus is on interpersonal interaction and learning from others who have similar issues. It's commonly used for issues like addiction, anxiety, depression, and grief, but it can address a wide range of psychological topics.

• Common Techniques: Group discussions, role-playing, feedback from group members, and structured exercises. It provides a safe space to practice new behaviors, gain insight from others, and receive emotional support.

What are the pros of group therapy?

• Provides social support and a sense of belonging.

• Helps individuals gain perspective by listening to others’ experiences.

• Encourages learning through shared experiences.

What are the cons of group therapy?

• Less personalized than individual therapy.

• Group dynamics can be challenging, and some may feel uncomfortable opening up in front of others.

What are support groups?

These are typically informal gatherings of people who share a common problem or life experience (e.g., grief, addiction, chronic illness). Unlike structured therapy, they rely more on peer support and less on a trained therapist’s guidance.

What is the evidence for support groups?

• Social Support: Research shows that support groups can provide emotional and psychological benefits by offering a sense of belonging and reducing feelings of isolation.

• Peer Learning: People can gain valuable insights and coping strategies from others who share similar experiences.

• Improved Coping: Support groups can help individuals manage stress, grief, and other emotional challenges more effectively.

What is the evidence against support groups?

• Limited Professional Guidance: Since support groups are often peer-led and not always facilitated by trained therapists, there’s a risk of misinformation or ineffective coping strategies.

• Potential for Negative Group Dynamics: In some cases, group members may reinforce negative behaviors or thoughts, especially if the group lacks professional facilitation.

• Not a Replacement for Therapy: While helpful, support groups are generally not a substitute for more formal psychotherapy, especially for those with complex or severe mental health issues.

What is Interpersonal Therapy?

• a form of psychotherapy that focuses on helping clients improve current relationships

What is Gestalt Therapy?

• a form of psychotherapy whose goal is helping the client become aware of their thoughts, behaviours, experiences, and feelings and to “own” or take responsibility for them

  • gestalt therapists are encouraged to be enthusiastic and warm towards their clients

  • to help facilitate the client’s awareness, gestalt therapists also reflect back to the client their impressions of the clients

  • gestalt therapy emphasizes the experiences and behaviours that are occurring at that particular moment in the therapy session

  • clients are also encouraged to put their feelings into action

What is electroconvulsive therapy (ECT)?

• a treatment that involves inducing a brief seizure by delivering an electric shock to the brain, also sometimes called shock therapy

  • ECT is used to primarily treat severe depression that has not responded to anti-depressant medications, and also has been shown to be effective in the treatment of bipolarr disorder

What is transcranial magnetic stimulation?

• a treatment that involves placing a powerful pulsed magnet over a person’s scalp to alter neuronal actvitiy in the brain

  • when TMS is used as a treatment for depression, the magnet is placed above the right or left eyebrow in an effort to stimulate the right or left prefrontal cortex (areas of the brain implicated in depression)

  • TMS has fewer side effects than ECT

What is psychosurgery?

• surgical destruction of specific brain areas

  • psychotherapy is rarely used these days and is reserved for extremely severe cases for which no other interventions have been effective, and when the symptoms of the disorder are intolerable to the affected person