Download Treatment

Treatment
Psychosurgery
Use of treatment
- Psychosurgery is an extreme
form of somatic treatment and
was mainly used before the
introduction of drug therapy. It
involves the cutting of neural
tissue in the brain and was
designed to change a
psychological condition.
- Jacobsen et al. (1935)
removed the frontal lobes of an
emotionally disturbed
chimpanzee called Becky,
reducing her temper tantrums.
Moniz (1937) was inspired to
reduce anti-social behaviour in
humans in a similar manner.
Mode of action
- The first technique was the
lobotomy, developed in the
1940s as a cure for
schizophrenia. This involved
removing large portions of the
frontal cortex or severing the
connection between the frontal
cortex and the lower centres of
the brain. In the UK, 10,000
were performed between 194252.
- In the 1960s this procedure
was replaced by the pre-frontal
leucotomy, thought to be less
extreme, which involved drilling
two holes in either side of the
skull and inserting a pointed
instrument to cut specific nerve
fibres.
- A more recent procedure is
the cingulotomy, where a tiny
cut is made in the cingulum
nerve fibres, using an electrode
needle which is guided by
magnetic resonance imaging,
making the procedure much
more precise. Alternatively,
amygdalotomies, where the
amygdala is cut. Both of which
are areas involved in anger and
emotion.
Appropriateness
In the 1950s and 1960s some
amygdalotomies resulted in
patients who were confused,
lacking in motivation and unable
to work (Eysenck and
Eysenck,1989).
Effectiveness
Psychosurgery continues to be
regarded as the most
controversial of all treatments
for mental disorders. The
procedure is irreversible
because once neural tissue has
been destroyed it stays
destroyed and there is no
guarantee that the procedure
will have a beneficial effect.
- Significant bad effects were
found with the earlier lobotomy
operation, such as withdrawal,
stupors, seizures and even
death. The more recent
leucotomy procedure is less
severe, but there are still
dangers involved.
- Prefrontal leucotomies are
occasionally used in cases of
severe depression, obsessivecompulsive disorder or pain
where all other treatment has
failed (Griest, 1992). Minimal
intellectual damage is caused
because of refined techniques.
- osgrove et al. (1996) report
successful treatment of
patients with depressive or
anxiety disorders using
cingulotomies. These patients
had not benefited from all
other available therapies. It is
possible that psychosurgery can
be effective if it is performed
precisely and on the right
patients.
Ethics
It is irreversible, and
the effects are not
consistent. Informed
consent is an issue
Electro-convulsive therapy
(ECT)
ECT is generally used in
severely depressed patients for
whom psychosurgery and
medication have proven to be
ineffective. It can also be used
for those who suffer from
A patient is given an
anaesthetic and muscle
relaxant. A sub-lethal (70-130
volt) electric shock is applied to
the non-dominant cerebral
hemisphere (unilateral) to
There is some discomfort about
using a method which cannot be
explained; it may not be the
seizure which is important at all
(Abrams, 1997).
- The method has some risk.
ECT is a controversial
treatment, not least because
the people who use it are still
unsure of how it works - a
comparison has been drawn with
kicking the side of the
In the past ECT
involved broken bones
and severe memory loss,
the treatment today is
more humane but is still
regarded by some as
schizophrenia and manic
depression. ECT is employed
when there’s a risk of suicide as
they are much quicker than
drugs. ECT should only be used
when all else fails!
produce a seizure. The
individual awakens and
remembers nothing of the
treatment, but may suffer longterm memory loss. A course of
treatment usually involves six
sessions.
- It is thought that the
convulsion causes chemical
changes in the brain in a way
that improves the person’s mood
state. The shock activates
nonadrenaline transmission,
reduces serotonin re-uptake
and increases sensitivity of
dopamine receptors, all of which
may help alleviate depression
The original procedure was
bilateral, i.e. the current passed
through both cerebral
hemispheres of the brain. The
patient was awake prior to the
seizure. Later, a strong muscle
relaxant and an anaesthetic
were given prior to treatment in
order to reduce the body being
out of control and the damage
that could be caused as a result.
The procedure used now is also
unilateral, passing the current
through the non-dominant
hemisphere only (Abrams et al.
1991). It was thought that
memory loss allows
restructuring of disordered
thinking. However, unilateral
ECT leads to minimal memory
disruption yet is still effective.
- ECT is still used today, though
the mortality rate is now very
low at 3.6 per 100,000
treatments. This is about the
same number of people who die
from anaesthetic in minor
surgery.
Drug therapies are safer but
ECT offers faster relief than
drugs, which is important for
suicidal patients.
There are physical side effects
such as impaired memory,
headaches. 1/3 of patients
suffer from memory loss.
television set to make it work.
When ECT was first introduced
there were dangerous side
effects, such as bone
fractures, memory loss and
confusion. There are no
detectable changes in brain
structure with the newer
unilateral procedure and, as the
technique is continually
improved, side effects are
being reduced.
- ECT remains controversial; it
requires consent from the
patient or close relative and is
only used when other methods
have failed.
- ECT is now rarely used for
schizophrenia; however, it
appears to be successful for
cases of severe depression.
Klerman (1988) maintains that
ECT may be the best treatment
for severe depression. Janicak
et al. (1985) found that 80% of
all severely depressed patients
respond well to ECT, compared
with 64% given drug therapy.
ECT has been successful in
treating severe depression in
patients where all other
methods have failed and many
argue that this is sufficient
justification for its use,
especially if it prevents suicide.
- However, Sackheim et al.
(1993) found that there was a
high relapse rate within a year
suggesting that relief was
temporary and not a cure.
abusive.
- The Department of
Health (1999)
considered 700 patients
who received ECT were
sectioned; 59% had not
consented to treatment.
Chemotherapy/Drugs
Anti-anxiety drugs: includes the minor tranquillisers such as
Librium and Valium. They were introduced in the 1950s and 1960s
and soon became the most prescribed drugs in the world. They are
used to reduce the symptoms of generalised anxiety disorders and
to combat withdrawal symptoms from alcohol addiction, etc. Side
effects include drowsiness and addiction. Buspirone has fewer side
effects.
Anti-depressant drugs: These are stimulants e.g. monoamine
oxidase inhibitors (MAOls), tricyclics, selective serotonin reuptake
inhibitors (SSRls, e.g. Prozac). Prozac is the newest of the antidepressant drugs. [It has been called the ‘happy pill’, 500,000
people in Britain take it.] They promote activity of nonadrenaline
and/or serotonin, leading to increased arousal but can be affected
by rebound (depression after initial euphoria). It regulates mood,
causes relaxation and controls aggression. They can be effective in
treating depression, but they do not work for all patients. They can
also be used to treat phobias. Side effects include dizziness.
Anti-manic drugs: These are used to control the mania in those
suffering from manic-depression. They were discovered through
the work of John Cade, an Australian physician. He conducted
lithium carbonate tests on guinea pigs, after inducing mania by
injecting urine from manic patients. Cade then tested his lithium
preparation on manic patients and found that their manic euphoria
had calmed within a few days. By the 1970s lithium carbonate had
become the routine treatment for manic-depression. Within two
weeks of taking them, 70 - 80 % of manic individuals show an
improvement in mood. Side effects include damage to the
cardiovascular system.
Anti-Psychotic drugs: These are used in the treatment of
schizophrenia. They are major tranquillisers, which sedate the
person and reduce such symptoms as thought disorder, withdrawal,
delusions and hallucinations. They tranquillise without impairing
consciousness. The result of these drugs is that they allowed
schizophrenics to live outside of mental institutions. They have
been called pharmacological straitjackets as they control people.
They do not cure the person but alleviate the symptoms. They
include chlorpromazine, used to treat schizophrenia. They block
dopamine receptor sites. Possible side effects include blurred
vision and a decrease in white blood cells (which can be fatal).
The use of drug therapies has
offered significant relief to
many sufferers, leading to
deinstitutionalisation. In 1955
there were 560000 patients in
American psychiatric
institutions. By 1977 this had
declined to 160000.
Drugs are reasonably effective
for treating certain mental
disorders and are readily
available, easily administered
and cost-effective. It can be
easier and quicker for GP’s to
prescribe drugs than to engage
in counselling [for which they
may not be trained].
Drugs have worked where all
other treatments have failed.
However, there are problems of
addiction and dangerous sideeffects (as indicated above).
Drugs are not cures; they are
short-term remedies that may
become long-term.
Chemotherapy leads to the
revolving-door phenomenon,
patients being continually
discharged and readmitted.
Also, drugs do not necessarily
provide a long-term cure, when
the person stops taking the
drugs, the symptoms may recur.
They treat the symptoms but
do not treat the problem. But
people may prefer to take them
because taking tablets are a
familiar activity, unlike other
therapies.
Effectiveness varies between
individuals, detracting from its
power as a therapy. For
example, Spiegel (1989) found
65% of depressed patients
improved using tricyclics.
Gerbino et al. (1978) report
that manic-depression is
controlled by lithium in about
80% of patients and has
considerably reduced the
suicide rate.
Drugs can be effective when
used in conjunction with
psychotherapy; they relieve
disabling symptoms, allowing the
contributing psychological
factors to be dealt with.
Drugs may have a placebo
effect - the person feels that
they are better because they
are taking a pill, irrespective of
what is in the pill. Has the drug
helped, or has the person
helped themselves?
Alternatively, the person may
have got better without the
drug. Their improvement
coincided with taking the
tablet. Drugs may be effective
because the patient believes
that the doctor expects them
to improve and this can affect
their health.
Drug therapies are
chemical-straitjackets,
infringing individual
rights.
The use of
chemotherapy may
prevent the use of
other methods.
Alternatively it may
enable patients to be
receptive to other
methods.
Drugs may be necessary
as a means of
protecting society at
large from individuals
who are dangerous.
However, patients living
outside institutions may
fail to take their
medication and pose a
serious danger.