Disorders

Who Gets What?

Prevalence of Neurotic Disorders by Age

Prevalence of Neurosis by Age & Social Class

Prevalence of Psychosis by Age & Gender

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

Incidence & Prevalence

Schizophrenia: approx. 1% Bipolar Disorder: approx. 1% Depression: approx. M 13% F 21%

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

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

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”

Psychological TreatmentOverview 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

Who provides treatment? Clinical psychologists

Psychologists

Neurologists

Psychiatric Nurses

Marriage and Family Counselors

Social workers

School counselors

Who seeks treatment? People with mental illness, hoping to relieve

pain and dysfunction

People with subsyndromal disorders

People looking for assistance in recovering from grief, anxiety, confusion, relationship issues… Women European Americans Financially well off

Psychological Treatments

Focused on changing the way the patient thinks and behaves

Involves discussion, instruction, or training

Over 500 different forms of such treatment Psychodynamic Humanistic Behavioral Cognitive

Psychodynamic Approaches Illness result of unconscious conflicts developed early in

childhood

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 creating meaning

Clients need to take responsibility for their lives and actions, and live in the “here and now”

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

Humanistic Approach Creating the therapeutic environment

Genuineness- sharing authentic reactions

Unconditional positive regard Non-judgmental, accepting

Empathic Understanding- putting oneself in the patients’ shoes

Humanistic Approaches Gestalt Therapy (Fritz Perls)

Mental illness is result of inconsistencies in one’s understanding of the self

Increase self-awareness and self-acceptance

Ask how clients felt, and point out discrepancies in the way they appeared

Empty chair technique

Behavioral Approaches

Reaction to Freud’s psychoanalysis

Viewed Freud’s approach as too unscientific

Treatment directed at reducing or eliminating problematic behaviors

Approach involves replacing old habits with more effective or adaptive behaviors Classical conditioning, operant conditioning, modeling

Behavioral ApproachesClassical 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 ApproachesOperant 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

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 A (acting event) B (belief) C

(consequence)

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

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

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

Biomedical TreatmentsThe Early Gruesome Years Trephination

Allowed “evil spirits” to escape the skull

Hot or Cold Baths

Spinning

Biomedical TreatmentsPsychosurgery

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

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

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

Deinstitutionalization

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

Emerging Biomedical Treatments

Repetitive TMS Areas of the brain stimulated

with magnetic coil for 20-30 minutes over several weeks

Effective for medication-resistant depression

No cognitive side effects

Deep Brain Stimulation Electrodes implanted in brain

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

Efficacy vs. Utility Difficult to run RCT for psychotherapy

Waitlist Manualized Therapy

Controlled studies allow researchers to come to conclusions about the efficacy of particular treatments

In many circumstances, patients have more than one illness

Also, therapists typically use more than one approach

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

Shop around!

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

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!