Introduction Clinical Psychology: disorders of the brain or of the mind

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Introduction Clinical Psychology disorders of
the brain or of the mind ?

• Professor Michael Joseph
• PS 3013. Clinical Health Psychology
• 05.10.04

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Ab-normal psychology

• How to define ? - the study of behaviour outside
  the normal range.
• Behaviour includes language, in humans, and by
  inference therefore, mental state.
• Could define abnormal statistically.
• However, a behaviour might be quite common, and
  we would still want to define it as abnormal.
• Concept of extreme rather than uncommon.

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Social Dimension

• Abnormal psychology is constrained from
  extreme we do not usually include extremely
  altruistic, truthful, happy.
• Need to bring in the context, the social
  dimension, appropriateness the behaviour is
  disturbing to the patient to their social
  functioning and relationships.
• This leads us to the use of social factors in any
  definition (e.g. those from p. 20 in Seligman et
  al. - see next slide).
• The more criteria that are met, the more
  significant the abnormality. 

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Seligman et al., criteria

• Suffering, Maladaptiveness,
• Irrationality and incomprehensibility,
• Unpredictability and loss of control,
• Vividness and unconventionality,
• Observer discomfort,
• Violation of moral and ideal standards.
•  
• Clearly borderlines are difficult to define.
• Criteria are culturally dependent.

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Clinical psychology

• can be defined as the study of mental states and
  behaviour in patients falling within the remit of
  psychiatry and neurology.
• This is then a clinical or medical definition.
• Links naturally to medical or health psychology.
• Neurology is the study of brain illness
  psychiatry is the study of mental illness, or
  mind illness. literally mind-treatment.
  
• Study of brain illness ought to be called
  Neuriatry.

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Neurology its a steal

• SO, the word Neurology has been stolen from the
  normal to the clinical (abnormal) by the medics.
• Could it be that the medics just wanted to get
  ahead of us Psychologists in alphabetical lists ?
• This is only half a joke the issue may be
  symptomatic of the sometimes fraught relations
  between clinical psychologists and clinicians.
• You may well hear about, or pick up more about,
  this from others, but I couldnt possibly
  comment.

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Psychiatry and Psychology

• Neuropsychology has a special meaning the
  psychology of neurological illness.
• However it means brain-mind-study, and thus
  ought to cover all of psychology.
• The distinctions between Neurology and Psychiatry
  are becoming blurred, given that the functions of
  brain and mind appear to be converging as we
  learn more about them.

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Schools of thought in Psychiatry, Neurology and
Psychology I

• Clinical psychologists also get involved in
  mind- treatment (psychotherapy, cognitive
  behaviour therapy), which is also a form of
  brain-treatment.
• The major difference is that psychiatrists and
  neurologists can use other brain treatments, i.e.
  drugs, and indeed surgery, where appropriate.
• Cartesian dualism (mind/brain) separation of
  illnesses of the mind from diseases of the brain
  psychological and neurological treatments evolved
  separately.

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Schools of thought in Psychiatry, Neurology and
Psychology II

• Physical treatments were developed in neurology,
  where there was direct physical evidence of brain
  involvement (lesions, brain injury, etc).
• Psychological treatments were developed in
  psychiatry, which reached their early apogee in
  the work of Freud.
• Freud wanted a scientific theory of neurosis,
  with universal governing principles
• He was trying not only to treat the symptoms
  themselves, but their underlying causes.

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Schools of thought in Psychiatry, Neurology and
Psychology III

• Also he believed that the applicability of
  psycho-analysis to the treatment of psychosis
  (schizophrenia, depression) was necessarily
  limited.
• However illness of the brain, clearly do lead to
  mental and behavioural changes.
• And it is only from changes of behaviour, and
  inferred changes in mental phenomena that
  we can infer illnesses of the mind.

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Schools of thought in Psychiatry, Neurology and
Psychology IV

• Thus it is possible that psychiatric disorders
  too could have origins in abnormalities in the
  brain.
• When we see behavioural changes reminiscent of
  those displayed by psychiatric patients arising
  from physical causes, this also suggests this
  possibility.

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Physical causes for psychiatric symptoms

• Examples
• syphilis - dementia, grandiose delusions
• hallucinogenic drugs - hallucinations
• drug abuse - amphetamine/cocaine
  psychosis
• temporal lobe epilepsy - automatisms,
  flight of ideas

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Biological psychiatry I

• was the important next stage in the development
  of psychiatry, closely associated with the
  discovery of drugs which were truly effective in
  treating psychiatric disease.
• In the second quarter of the 20th century,
  neuropharmacology made rapid strides,
  establishing the reality of chemical transmission
  between neurones in the nervous system.
• It also generated the tools which permitted the
  pharmacological analysis of many new compounds
• these could be synthesised using the chemical
  knowledge developed in the 19th and early 20th
  centuries.

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Biological psychiatry II

• In this early period, many new drugs became
  available for medical use, but none of these were
  directed at psychiatric disorders.
• Beyond the use of non-specific sedatives, no-one
  had any idea where to start, since the
  neurobiology of psychiatric disorders was at best
  unknown.
• At the worst it was non-existent - many still
  thought them to be of purely psychological origin
  - or even plain wrong, e.g. epilepsy,
  schizophrenia and ECT, or insulin coma therapy
  (abuse).

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Psychoses I

• Chlorpromazine (CPZ), revolutionised the
  treatment of schizophrenia, and also the
  atmosphere in psychiatric hospitals.
• Minor manipulation of the molecular structure of
  CPZ produced imipramine, an effective treatment
  for endogenous depression, the other common
  psychosis. This was the first of the tricyclic
  drugs.
• Another treatment for depression, the MAOIs, of
  which the first was iproniazid, came from the
  observation of an anti-depressant action of a
  modified form of the anti-tubercular drug
  isoniazid.

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Psychoses II

• The monoamine theory of depression was
  consolidated when it was found that depression
  could be precipitated by reserpine this has
  opposite pharmacological actions to tricyclics
  and MAOIs
• Cade, in Australia discovered variations in the
  excretion of uric acid in manic-depressive
  psychosis. Wanted to treat with uric acid. Used
  the lithium salt of uric acid, as the most
  soluble one available.
• The treatment was remarkably effective, indeed
  also prophylactic, as developed by Schou, but the
  Lithium was doing the work, not the uric acid
  part.

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Anxiety Drugs in psychiatry

• Benzodiazepines were developed from the
  observation that a series of synthetic compounds
  exerted a taming effects in animals, and they
  proved to be remarkably effective in treating
  human anxiety.
• In all three clinical areas, drug treatments
  rapidly multiplied.
• Thus from a situation in 1950 when we had no
  drugs for specifically treating any of the major
  psychiatric disorders, within 10-20 years we were
  able to treat all of the major psychiatric
  disorders, in most cases with a choice of
  different agents.

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Drug administration and Psychosis

• This new evidence was added to that from symptoms
  produced by drug administration.
• We have already mentioned hallucinogenic drugs,
  which produced symptoms analogous to
  schizophrenic hallucinations.
• This led to the idea that in schizophrenics
  endogenous hallucinogens might be produced via
  abnormal metabolism
• Even better models of psychiatric disorders were
  produced by amphetamine (paranoid schizophrenia)
  and reserpine (endogenous depression), and more
  recently PCP (angel dust) - (psychosis).

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Actions of drugs

• Knowledge that these drugs, and the therapeutic
  ones mentioned earlier, acted on particular
  (chemical) subsystems in the brain led to the
  idea that overactivity or underactivity of
  particular systems might underlie psychiatric
  disorders.
• An important model was provided by a neurological
  condition, Parkinsons disease, which turned out
  to be a dopamine (chemical messenger) deficiency
  disease, and was treated effectively with the
  dopamine precursor L-dopa.

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Anti-psychiatry movement.

• In parallel to the dramatic developments in
  biological psychiatry, other psychiatrists were
  taking the extraordinary step of listening to
  their patients.
• They were saying that what other psychiatrists
  regarded as nonsense could have meaning, and that
  this meaning could throw light on the situation
  that these patients found themselves in. R.D.
  Laing
•  While the corollary, that schizophrenia was only
  appropriately treated by family therapy, was
  wrong, an important breakthrough was made, the
  results of which are still relevant today what
  patients say is not meaningless.

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Behaviour therapy

• Treatment developed using behaviourist
  principles.
• Psychiatric symptoms are simply behavioural
  problems, which can be eradicated using
  behavioural training techniques.
• The main disorders to which these were applied
  were anxiety, especially phobias, and sexual
  deviation (or as we now call it diversity).
• This of course was exactly the opposite approach
  to that of the Freudians, who believed that if
  the symptoms rather than the causes were treated,
  other symptoms would simply re-emerge.

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Brain disorder or mind disorder ?

• Thus by about 1970, debate had polarised as to
  whether the origin of psychiatric disorders was
  psychological or physiological, e.g.
  Schizophrenia as a brain disorder, or a mental
  disorder.
• This polarisation led to two exclusive
  approaches
• 1) an abnormality of the mind, of mental
  processes -hence treat by altering the mind
  psychotherapy, or cognitive, or behavioural
  therapy. 
• 2) an abnormality of the brain - hence treat by
  drugs the function of psychiatrists and
  psychologists is to provide a context where this
  can take place.

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Brain and mind order

• Nowadays few would subscribe to the theory that
  the mind is not firmly anchored in the brain, or
  that phenomena such as speech, memory and
  learning do not have physical counterparts in the
  brain
• From this position, since events influence
  brainstates, directly and indirectly, and
  brainstates produce behaviours, the debate seems
  pointless.
• It must be that a synthesis of these approaches
  is feasible and appropriate.

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Subsequent Events 1970-2000

• Biological basis for schizophrenia firmly
  established.
• (CRC) enlarged ventricles flupenthixol
  trial and dopamine block neuropathological
  changes
• Development of alternative and equally effective
  drugs led to wider understanding of their mode of
  action, and hence discovery of a wider range of
  drugs.
• Use of animal models which could be validated on
  this wider range led to the discovery of new
  classes of drugs with different modes of action,
  and often fewer side effects.

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Nature of Biological theories

• Most simple theories of deficiencies/excesses on
  a regional or neurochemical basis were ruled out
  as research progressed.
• Any physical lesions or changes in psychiatric
  disorders will be subtle, and by no means evenly
  distributed.
• They could have developmental origins.
• It also became apparent that the finding that
  doing X improved condition Y did not mean that Y,
  untreated, was characterised by the opposite of X

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Cognitive behaviour therapies

• have been developed and become established for
  the treatment of depression, and to some extent
  even for the treatment of schizophrenia. Thus
  the symptoms are amenable to cognitive control ,
  and meaningful - the legacy of Laing.
• The other outcome of the Laingian experience is
  that psychologists now look at symptoms from the
  point of view of obtaining information on which
  systems have gone awry in each disorder.

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Psychology, and interactions

• This has implications for treatment, and also for
  understanding normal functions, including
  attention, beliefs and the regulation of
  consciousness (Frith)
•  We now see pathological behaviour as arising
  from the interaction of social factors with
  vulnerable individuals.
• Thus it is appropriate both
• (a) to treat at the brain activity level,
  using drugs, which can often reverse distressing
  symptoms, and
• (b) to treat at the mental level, using
  treatments which can help to understand and deal
  with the background social factors. These might
  include counselling and psychotherapy, and social
  work.

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Drugs and psychological treatments

• Many trials now suggest that a combination of
  drug and psychological treatments do better than
  either one alone, especially in depression.
•  The fundamental vulnerability may not be
  alterable, at present, e.g. if developmental.
• Drugs can help to deal with the symptoms.
• They may also have a prophylactic action.
• We then need to consider what can be done to
  improve the social context and environment.

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Other approaches

• On the other hand, many degenerative disorders
  are due to an ongoing toxic process. If this is
  true for some psychiatric disorders, it might be
  possible to arrest it.
• We are gaining knowledge of how to re-construct
  the nervous system, although re-developing it
  promises to be a much harder problem. Doing
  proper controlled trials will be ethically
  difficult.
• Beware example of psychosurgery reversing any
  physical intervention in the brain (e.g.
  transplants, genetic manipulation) will be harder
  than simply taking patients off drug treatments.

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Bottom line I

• Clinical disorders are not EITHER psychological
  OR neurochemical/ neurophysiological
  disorders.
• Experience and behaviour ARE determined by
  activity within the brain, whether normal or
  abnormal
• Clinical disorders are almost certainly NOT
  simple in brain terms not simply a missing
  enzyme, or a missing transmitter or receptor.
• Drugs used to treat disorders, while often having
  one predominant or critical action, are complex
  in their actions in detail. Developing more
  pharmacologically specific drugs has rarely
  improved them

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Bottom line II

•  In principle, all clinical disorders can be
  helped by psychological treatments. Drugs may
  facilitate a reduction in symptoms, needed before
  psychological treatment can become effective.
•  In some conditions or individuals, continued
  drug treatment may be useful, or even essential,
  in protecting against relapse.
•  Psychological treatments are also likely to be
  useful, both in moderating specific experiences
  in the illness, and in having a prophylactic
  effect, protecting against precipitating factors
  in the environment.