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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.