Download Personal-Psychopath-treatment

Personality
Stability vs. Situation?
Personality
• Traits vs. States vs. Types
• 18,000 personality terms to 32 traits to• Big five:
– Extraversion (outgoing, sociable, positive)
– Neuroticism (prone to negative emotions)
– Conscientiousness (organized, efficient, disciplined)
– Openness to experience (non-conventional, curious)
– Agreeableness (trusting & easygoing with others)
40 to 60% heritable
Situationism
• Low correlations across situations
– Strong vs. weak situations
– But-brain differences and heritability
•
•
•
•
•
Introverts more sensitive to external stimuli
More reactive central nervous system
Low pain tolerance
Underactive Nor-epi system
Sensation seeking extraverts
Heritability: Big five correlations
• Identical twins vs. fraternal twins :
Identical
• Reared together- .51
• Reared apart.50
Fraternal
.23
.21
Personality Theories
• Psychoanalytic
– Childhood experience, ucs influence, dynamics,
conflict, defenses, development and identification
• Humanistic
– Focus on self & self-actualization, existential
approach, flow & happiness
• Social-Cognitive Theory
– Beliefs, thoughts & personal constructs, often acquired
from social interactions & imitation shape behavior
• Behavioral Theory
– Learning history, self-perception theory, self-control
Disorders
Who Gets What?
Defining Abnormality
• Medical approach
• Statistical approach
• Functional approach
These reflect two basic views of disorders
--brain based
--behavior/experience/situation based
The “two worlds” of psychiatry
DSM-IV
•
•
•
•
•
•
Axis 1: Syndromes (Scz, Depress, etc.)
Axis 2: Retardation & Personality Disorders
Axis 3: General Medical Condition
Axis 4: Social/Environmental Problems
Axis 5: Global Assessment & Coping
Older classification (primarily of Axis 1 & 2)
dichotomized: Neuroses & Psychoses
• Mood (Dep. Bipolar) vs. Thought (Scz) Disrdr
• Now replaced by highly elaborated DSM-V
Three Broad Types/Dimensions
• Personality (Psychopathy…..)
• Mood (Depression, Bipolar)
• Thought (Scz. Delusions, Hallucinations)
SCZ Manifestations/Symptoms
Positive symptoms:
-- Hallucinations
– delusions
– Disorganized or strange behavior & speech
• Negative symptoms:
– Flat affect & other behavior
– Catatonia
– Withdrawel from others
Prevalence of Neurotic Disorders by Age
Hollingshead & Redlech New Haven Study, 1958
Prevalence of Neurosis by Age & Social Class
Prevalence of Psychosis by Age & Gender
Treatment
Duration
& Social
Class
Psychosis: Age
and Social Class
Heritability of Psychosis: Schizophrenia
Scz incidence & poverty/residential area
Some Interim Conclusions
• Psychoses (focus on SCZ) is a disorder of
heredity and/or prenatal environment
• But it’s also a disorder of poverty (and
that may be bidirectional)!
• Another view of prevalence and recent
dramatic changes in prevalence
Deinstitutionalization
Prevalence
• Schizophrenia: approx. 1%
• Bipolar Disorder: approx. 1%
• Depression:
approx. M 13% F 21%
Basic Models of Disorder
Stress: Functional Disorder
-Cognitive & Social Origins
Illness: Medical/Biological
– Brain-based (synaptic & neural
network/connectivity)
Mixed Model: VulnerabilityStress
Szasz: Radical Anti-medical Approach
Treatment
Overview
• Brief History
• Psychological Treatments
• Biomedical Treatments
• Client-Therapist Relationship
• Is Treatment Effective?
History
• Earliest history
– Mental illness believed to be caused by evil
spirits. Hippocrates began to dismantle
this.
– Treatments were harsh, ineffective
• Drill holes in skulls to create exits for spirits
• Make the body horribly uncomfortable for the
spirits
• Purge demons through inducing vomiting
History
• Middle Ages
– Mental illness viewed more like a
disease, but not treated well!
– Mental institutions were created
• Purpose: confine “madmen”
• Included other social “undesirables”
• Inhumane treatment (shackles and chains)
Beginning of Reform
• Early to Mid 1800s
– Philippe Pinel put in charge of Paris’
hospital system
• Removed shackles and chains
• Patients allowed to exercise, venture outside
Beginning of Reform
• Dorthea Dix
– Fought for humane
treatment of
patients in U.S.
• 19th century
– Freud’s “talking
cure” (Charcot &
hypnosis)
Psychological Treatment
Overview
• Treatment involves addressing three
major components of the illness:
– Biological
– Psychological
– Social
• Something to keep in mind:
– These three major components are not
necessarily black-and-white/separable
Who provides treatment?
• Clinical psychologists
• Psychologists
• Neurologists
• Psychiatric Nurses
• Marriage and Family Counselors
• Social workers
• School counselors
• Clergy
Who seeks treatment?
• People with mental illness, hoping to relieve
pain and dysfunction
• People looking for assistance in recovering
from grief, anxiety, confusion, relationship
issues and other life challenges…tilted toward
–
–
–
–
Women
European Americans
Financially well off
People with Health Insurance (which increasingly
controls things)!
Psychological Treatments
• Focused on changing the way the patient thinks and
behaves
• Involves discussion, instruction, training,
relationship analysis
• Over 500 different forms of such treatment
–
–
–
–
Psychodynamic
Humanistic
Behavioral
Cognitive
Psychodynamic Approaches
•
Illness result of unconscious
conflicts developed early in
childhood with impact later
•
Defense mechanisms shield
from the inner conflict
– This can lead to
symptoms of mental
illness
•
Treatment: Uncovering
unconscious desires and
conflicts, and resolving them
– Integrate thoughts and
memories coherently
Psychodynamic Approaches
• “Working through” the conflict
– Transference
• Used as a therapeutic tool
• In order to be effective, therapist must
remain neutral
Humanistic Approaches
• Based off of Freud’s “talking cure”
• However, less focused on basic drives
• Instead, focus on decisions & creating meaning
• Clients need to take responsibility for their lives
and actions, and live in the “here and now”
• “Tomorrow is the 1st day of the rest of your life”
Humanistic Approaches
• Client-Centered Therapy (Carl Rogers)
– Focuses on achieving self-acceptance
– Does not pass judgment, or provide
instruction
– Aim is to create an environment
in which the client feels
understood and valued
-Requires & elicits a capable client
Humanistic Approach
• Creating the therapeutic
environment
– Genuineness- sharing authentic
reactions
– Unconditional positive regard
• Non-judgmental, accepting
– Empathic Understanding- putting
oneself in the patients’ shoes
Behavioral Approaches
• Reaction to Freud’s psychoanalysis
• Viewed Freud’s approach as too unscientific
• Treatment directed at reducing or eliminating
problematic behaviors (because behavior is all
there is!)
• Institutional control mechanism (humane?)
• Approach involves replacing old habits with more
effective or adaptive behaviors
– Classical conditioning, operant conditioning, modeling
Behavioral Approaches
Classical Conditioning Techniques
• Treatment of Phobias
– Extinguish the association between the
neutral stimulus and the fearful stimulus
– Exposure Therapy
• Train clients in deep muscle relaxation, pair
relaxation with the fearful stimulus
• Create a hierarchy of progressively more
frightening stimuli
• Systematic desensitization: gradual exposure to
the real phobic stimulus
Systematic Desensitization
Behavioral Approaches
Operant Conditioning Techniques
• Token economies
– Earn tokens for positive behaviors, which can be exchanged for
prizes
– Shaping
• Contingency Management
– Strict consequences for certain behaviors
• Successful for shaping communicative behavior in children
with autism (Lovaas)
• Modeling Techniques
– Therapist perceived as role model
Cognitive-Behavioral Approaches
• Rational Emotive Behavioral Therapy
(Albert Ellis)
• People typically think that an event
causes them to behave a certain way
– But…beliefs matter
– Focused therapy on changing beliefs
• Teacher-like
Cognitive Therapy
• Aaron Beck
• Focused on changing dysfunctional
thought
• Cognitive Restructuring
– Challenge a person’s unhealthy
beliefs or interpretations
– Used persuasion and confrontation
– Brief, problem-focused
• Initially treated depression
Cognitive-Behavioral Therapy
• Followers of Ellis and Beck blended the
two therapies to form CBT
• Focus on addressing problems the
patient wishes to solve
• Intimate relationship between behavior
and thought (self perception theory!)
• Often clients are assigned homework
– Practice new ways skills or thought
techniques
Eclecticism
• Modern therapy tends
to blend aspects from
many of these
perspectives
• Makes sense, since
there are often many
causes of mental
illness
Client-Therapist Relationship
• Therapeutic Alliance
– Support
• Trust
• Hope
• Understanding
Group Therapies
•
•
Often groups are chosen
because they share similar
problems (e.g., Alcoholics
Anonymous)
Focus on the shared
problems, less on the
individuals’ emotions
• Advantages
– Social support
– Share advice, information
– Observe other peoples’
successes
– Realize that not alone, others
share similar problems
– Economic advantage
Couple and Family Therapy
• Views the family or relationship as a
complex system
– One person’s negative behavior or
cognitions may reflect a larger issue for the
entire family or relationship
• Can be extended to
• treating children
who have little control
(work with family to change
situation/mileau)
Biomedical Treatments
The Early Gruesome Years
• Trephination
– Allowed “evil spirits” to escape the skull
• Hot or Cold Baths
• Spinning
Biomedical Treatments
Psychosurgery
• Prefrontal Lobotomy
– Sever connections between
thalamus and frontal lobes
– Disrupted higher cognitive
functions
• Modern techniques are more
precise and used as a last
resort treatment
Electroconvulsive Therapy (ECT)
•
Brief electrical current
passed through the brain
causing a convulsive seizure
•
Originally developed to treat
schizophrenia
•
Very effective for treating
severe depression (70-90%
effective)
•
Memory impairment
•
Mechanisms are not known
Different Therapies for Different
Conditions (& Sometimes a Mix)
• Medical: Brain targeted drug interventions
examples:
--SCZ: Dopamine receptor blockers (the
better the block the more effective it is)
--Other neurotransmitters involved as well
--Depression: ex. Norepinephrine uptake
or release+, Serotonin release+, & a host
of other neurotransmitter controls involved
-- Electro-convulsive shock therapy!
Pharmacological Treatments
• Psychotropic drugs
– Not only helped treat patients, but also
further understanding of the illness
Pharmacological Treatments
• Antipsychotics
– Treat positive symptoms of schizophrenia
– Not effective for treating the negative symptoms
– Most common are Thorazine, Haldol and Stelazine
• Block dopamine receptors in particular brain pathways
• Atypical Antipsychotics
– Treat negative symptoms of schizophrenia, too
– Risperdal, Clozaril, Seroquel
Antipsychotics and Deinstitutionalization
• Movement in the 1950s shortly after
development of the first antipsychotics
– Aimed to provide less expensive mental health care at
local community centers instead of institutions
• Pros
– Fewer people spending their lives in institutions
– Shorter stays
– Thomas Szasz argument
• Downside
– Lack of appropriate care in community settings
– Lack of integration into the community (support
services, employment)
– Many mentally ill are now homeless, or in jail
The next slides
• The next six slides are for informational
purposes to show the variety and nature of
particular psycho-pharmacological approaches
but should not be memorized!
Antidepressants
• Monoamine Oxidase Inhibitors (MAOIs)
– Nardil
• Tricyclic antidepressants
– Tofranil
• Increase serotonin and norephinephrine for
synaptic transmission
• Both very effective (significant improvement in
65% of patients)
– Many negative side effects
Antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
– Prozac, Zoloft, Paxil, Celexa, Lexapro
– Minimally effect dopamine and norepinephrine, and
maximally effect serotonin
• Reduced side effects
– Most commonly prescribed
• Atypical Antidepressants
– Effect serotonin, norepinephrine and dopamine in
various ways
• Wellbutrin (fewer side effects)
Antidepressants
• Downside
– Takes a while before effective (a month)
– Trial-and-error
– Side effects
• Weight gain, nausea, diarrhea, insomnia,
reduced sexual desire or response
Mood Stabilizers
• Treat symptoms of bipolar disorder
• Lithium carbonate
– Treats manic episodes as well as depressive episodes
– Side Effects
• Weight gain, sedation, dry mouth, tremors
– Adherence to medication
• Often patients do not wish to treat mania, only depression
– Lethal at high doses
– Effective for 60 – 70% of patients
Anxiolytic Medications
• Treat anxiety disorders
• Increase neurotransmission of GABA
• Beta Blockers
• Benzodiazepines
• Tricyclic Antidepressants and SSRIs
Anxiolytic Medications
• Beta Blockers
– Controls autonomic arousal
• Benzodiazepines
– Valium, Xanax, Klonopin
– Short term treatments
– Highly addictive
– Interact dangerously with alcohol
– New drugs are being developed to reduce these negative side
effects
– Rebound effect
Medication: Costs and Benefits
• Can be highly effective
• Only treats and controls the
symptoms
– Relapse
• Requires trial-and-error for
correct drug and correct dosage
• Side effects
– Reduce adherence to medication
• Overprescription
Outcomes:
Improvement
with Drugs vs.
Placebos
Emerging Biomedical Treatments
• Repetitive TMS
– Areas of the brain stimulated
with magnetic coil for 20-30
minutes over several weeks
– Effective for medicationresistant depression
– No cognitive side effects
• Deep Brain Stimulation
– Electrodes implanted in brain
- Future: increased ability to
interface with brain sub-areas
via many pathways.
Combined Treatments
• Most therapists use a combination of
treatments
– Drug treatments for short-term effects
– Therapy for long-term effects
Evaluating the Efficacy of Treatments
• Randomized Clinical Trial (RCT)
– Treatment group
– Placebo group
– Random assignment
– Symptoms and severity similar across
participants
– Follow participants over several months
Is therapy effective?
• A meta-analysis found that 80% of
patients who received treatment
fared better than those without
Are all Therapies Equally Effective?
Who provides the most effective psychological
treatment?
• Number of years of practice?
– Not necessarily
• Professional credentials?
– No
• The rapport between therapist and
client seems to be strongest predictor
– Respect, trust, comfort
Who is most likely to benefit from
treatment?
• Strong alliance with therapist
• Motivated
• Optimistic
• More effective with more therapy
Are All Treatments Equally Effective?
• A depression meta-analysis shows…
– Drug treatment alone 55% effective
– Therapy alone 52% effective
– Drug AND therapy 85% effective!
(New England Journal of Medicine, 2000)
Are all Treatments Equally Effective?
• Treatment more effective than no
treatment
• Combining treatments appears most
beneficial
• Some therapies seem particularly
effective for specific disorders
– Exposure therapy phobias
Moral of the Story
• Treatment is effective!
• Modern treatments are much more
effective and humane than past
treatments
• The relationship between therapist
and client really matters!
Recent Reconceptualization
• Some people are able to cognitively
overcome even serious levels of
disorders
– Available to psychotherapy
– Find meaning in some symptoms
– Able to live normally or quasi-normally
– Example in Nash film and in today’s reading
If you feel you need help…
• Seek it! Ask for advice, or set up an appointment
with a counselor. It’s not a weakness.
• Make sure the therapist is a good match for you!
• Remember it can take time and you may face
some setbacks, but also…
• Remember treatment is effective! Most people
improve!
Overview
• The “Two Worlds” of psychiatry approach is
flawed.
• The brain is the source of behavior and thus a
possible route of change via medical
intervention, but….
• Behavior and experience can modify the brain,
thus psychotherapy, while targeting behavior,
also “tunes the engine” by acting on the brain.