PSY 100Y5 TREATMENT OF DISORDERS LECTURE DR. KIRK R. BLANKSTEIN

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PSY 100Y5TREATMENT OF DISORDERS LECTUREDR. KIRK
R. BLANKSTEIN

• OUTLINE
• Overview
• Biopsychosocial Model
• Biopsychosocial Assessment
• Multifaceted Interventions (Biological,
  Psychological, Social)
• How Does Treatment Differ From Friendship?
• SCHIZOPHRENIA Causes and Treatment
• Review of Symptoms and Subtypes
• A Diathesis-Stress Model of Causes
• Biological Treatment
• Psychosocial Interventions
• Civil Commitment in Ontario
• ANXIETY Causes and Treatment
• Review of Symptoms and Subtypes
• An Integrated Causal Model
• Panic Disorder
• Test Anxiety?
• Cognitive Behaviour Therapy

VIDEO
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The BIOPSYCHOSOCIAL Model
Psychological factors personality cognitive
style social skills symptoms of psychopathology
(diagnosis)
Biological factors brain structure neurochemistry
hormones autonomic nervous system functions
Social factors marital adjustment family
functioning peer relationships work school
satisfaction
The clinicians conceptual approach to a persons
problem will determine the selection of
assessment instruments. This figure lists
examples of variables that might be considered
within each broad conceptual level.
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Levels of Analysis in ASSESSMENT
Psychological factors personality cognitive
style social skills symptoms of psychopathology
(diagnosis)
Biological factors brain structure neurochemistry
hormones autonomic nervous system functions
Social factors marital adjustment family
functioning peer relationships work school
satisfaction
The clinicians conceptual approach to a persons
problem will determine the selection of
assessment instruments. This figure lists
examples of variables that might be considered
within each broad conceptual level.
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Modes of Assessment

• Clinical psychologists typically employ three
  primary modes of assessment

• INTERVIEWS gather information from the persons
  point of view.
• TESTS can be objective or projective.
• DIRECT OBSERVATION may be used as signs or
  samples of behavior.

• The model or perspective subscribed to by the
  assessor influences the assessment
• e.g., the interview conducted by a
  psychoanalytically oriented clinician is very
  different from a behavior therapists interview.

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CASE FORMULATION The therapists hypothesis
about the nature of the psychological mechanisms
underlying the clients difficulties
COGNITIVE-BEHAVIOURAL CASE FORMULATION PERSONS'
APPROACH

• DOES THE CASE FORMULATION IMPROVE
  TREATMENT OUTCOME?
• DIFFERS FROM BEHAVIOURAL ANALYSIS IN
  PLACING MUCH MORE EMPHASIS ON UNDERLYING
  COGNITIONS
• VIEWS CLIENTS PROBLEMS AS EXISTING AT TWO
  LEVELS
• ? OVERT DIFFICULTIESthe actual problems in
  living that clients seek help for (e.g.,
  depression, relationship difficulties)
• ? UNDERLYING MECHANISMSthe underlying (central)
  psychological mechanisms that produce and
  maintain the overt difficulties (e.g.,
  dysfunctional attitudes or beliefs about the
  self, others, and the world schemas or networks
  of related dysfunctional attitudes)

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THE MODEL
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CLINICAL APPLICATION OF THE PERSONS
CASE FORMULATION MODEL

1. PROBLEM LIST 2. DIAGNOSIS 3. WORKING
HYPOTHESIS 4. STRENGTHS ASSETS 5. TREATMENT
PLAN
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CRITICALTHINKING

• DO YOU THINK THAT THERE ARE ADVANTAGES ( AND
  DISADVANTAGES) IN GETTING HELP FOR PSYCHOLOGICAL
  PROBLEMS FROM A FRIEND RATHER THAN FROM A
  PROFESSIONAL THERAPIST? WHAT ARE THE ADVANTAGES
  (AND DISADVANTAGES) OF GETTING HELP FROM THE
  PROFESSIONAL THERAPIST RATHER THAN FROM YOUR
  FRIEND?

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How Does a Therapist Differ From a Friend?

• Advantages of getting help from a friend rather
  than a therapist
• COST
• LESS STIGMA
• CONVENIENCE
• INTIMATE KNOWLEDGE

• Advantages of getting help from a therapist
  rather than from a friend
• EXPERT OPINION
• KNOWLEDGE OF RESOURCES
• UNDERSTANDING OF SERIOUS PROBLEMS
• CONFIDENTIALITY
• OBJECTIVITY
• SEPARATION FROM PERSONAL LIFE

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TARASOFF AND THE DUTY TO WARN AND PROTECT
POTENTIAL VICTIMS

• PROSENJIT PODDAR KILLED TATIANA TARASOFF ON
  OCTOBER 27, 1969.
• THE CALIFORNIA SUPREME COURT RULED THAT PODDARS
  THERAPIST (A CLINICAL PSYCHOLOGIST AT THE
  UNIVERSITY OF CALIFORNIA AT BERKELEY) SHOULD HAVE
  WARNED TARASOFF THAT HER LIFE MIGHT BE IN DANGER.

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Psychoanalysis FREUDS CLASSIC TREATMENT FOCUSES
ON CHILDHOOD MEMORIES AND UNCONSCIOUS CONFLICTS
TECHNIQUES INCLUDE FREE ASSOCIATION, DREAM
ANALYSIS, TRANSFERENCE, AND INTERPRETATION
SEVERAL MEETINGS A WEEK FOR SEVERAL YEARS
THERAPIST ALOOF.
Ego Analysis PSYCHODYNAMIC TREATMENTS DEVELOPED
BY SULLIVAN, HORNEY, ERIKSON, AND OTHER FOLLOWERS
OF FREUD INSIGHT IS GOAL BUT THE PRESENT, THE
CONSCIOUS MIND, AND SOCIAL RELATIONSHIPS (THE
EGO) CONSIDERED BY MORE ACTIVE, WARM THERAPIST.
LONG-TERM BUT SHORTER THAN PSYCHOANALYSIS
Psychodynamic Psychotherapy MANY VARIATIONS OF
THIS SHORT-TERM INSIGHT-ORIENTED TREATMENT
THERAPIST IS MORE DIRECTIVE OR CONFRONTATIONAL IN
INTERPRETING DEFENSES TREATMENT FOCUSES ON
SINGLE ISSUE OR THEME
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Criteria for a Panic Attack
A discrete period of intense fear or discomfort
in which four (or more) of the following symptoms
developed abruptly and reached a peak within 10
minutes.

• palpitations, pounding heart, accelerated heart
  rate
• sweating
• trembling or shaking
• sensations of shortness of breath/ smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, faint or lightheaded
• derealization or depersonalization
• fear of losing control or going crazy
• fear of dying
• paresthesias (numbness or tingling sensations)
• chills or hot flushes

1) Cued or Situationally Bound 2) Situationally
Predisposed 3) Unexpected (Uncued)
TYPES
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Typical Situations Avoided by a Person with
Agoraphobia

• Shopping malls
• Cars
• Trains
• Buses
• Subways
• Wide streets
• Tunnels
• Restaurants
• Theatres

• Supermarkets
• Stores
• Crowds
• Planes
• Elevators
• Escalators
• Waiting in line
• Being far from home

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Anxiety and Panic An Integrated Causal Model
Biological Factors

• genetics
• neurobiology (BIS, FFS)

Psychological Factors
Social/Environmental Factors

• sense of controllability
• conditioning
• cognitions/expectancies of danger
• anxiety sensitivity

• stressful life events
• social pressures to succeed

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Differential Diagnosis
Anxiety Disorder GAD Panic Disorder Specific
Phobia Social Phobia PTSD OCD

• Focus of the Anxiety
• minor everyday events
• the next panic attack
• specific situations/objects
• embarrassment/evaluation in social situations
• avoidance of thoughts/images of past trauma
• avoidance of intrusive thoughts or
  neutralization through rituals

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Panic Disorder with and without Agoraphobia

• Panic Disorder (PD)
• recurrent unexpected panic attacks
• one month of anticipatory anxiety OR a
  significant change in behaviour related to the
  attacks
• Panic Disorder with Agoraphobia (PDA)
• anxiety about being in places or situations from
  which escape might be difficult or embarrassing
  in the event of a panic attack
• situations are avoided or are endured with
  marked distress or anxiety about having a panic
  attack OR require the presence of a companion

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Overview Cognitive-Behavioral Treatment
Strategies

• 1. Psychoeducation
• 2. Rationale/Goals for Treatment
• three components of fear/anxiety
• 3. Exposure (Response prevention ?)
• to feared objects, situations
• imaginal vs. in vivo
• hierarchy
• 4. Modeling
• 5. Interoceptive Exposure
• 6. Breathing Retraining
• 7. Deep Muscle Relaxation
• 8. Cognitive Therapy (Restructuring)
• probability overestimation, catastrophic
  cognitions, self-talk

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Overview Cognitive-Behavioral Treatment
Strategies -- continued

• 9. Social Skills/Assertiveness Training
• 10. Coping Skills
• 11. Problem Solving
• 12. Homework
• handouts, tapes, self monitoring
• 13. Pharmacotherapy
• SSRIs, high potency benzodiazepines, TCAs

Variation individual vs. group
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Treatment for Panic Disorder
1. Exposure to Agoraphobic Situations 2.
Interoceptive Exposure 3. Cognitive Therapy 4.
Breathing Retraining 5. Relaxation Therapy 6.
Medication (imipramine, alprazolam)
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Principles of Effective Exposure

• Duration of Exposure
• Massed vs. Spaced Exposure
• Graduated Exposure vs. Flooding
• Structuring Exposure Sessions in Advance
• Predictability
• Perceived Control
• Distraction, Safety Signals, Overprotective
  Behaviors
• Imaginal vs. in-vivo Exposure
• Fighting the Fear
• Focus of Attention (e.g., on finding an escape)
• Measuring Success
• Integrating Exposure and other Strategies
• Overlearning

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Exposure Hierarchies Example of Height Phobia
1. Standing on a chair 2. Standing on a
table 3. Standing ten steps up on a ladder 4.
Looking out of a 12th floor closed window 5.
Looking over a second floor open balcony 6.
Looking over a fifth floor open balcony 7.
Looking over a tenth floor open balcony with
water below 8. Looking over a tenth floor open
balcony with concrete below 9. Going up the CN
Tower looking out the window 10. Going up
the CN Tower and stepping out onto the
observation deck
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Typical Situations Avoided by a Person with
Agoraphobia

• Shopping malls
• Cars
• Trains
• Buses
• Subways
• Wide streets
• Tunnels
• Restaurants
• Theatres

• Supermarkets
• Stores
• Crowds
• Planes
• Elevators
• Escalators
• Waiting in line
• Being far from home

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Becks Cognitive- Behavioral TherapyThree-Column
Technique

• EVENT AUTOMATIC
• NEGATIVE
• THOUGHTS
• My boyfriend Hes losing interest
• didnt call on in me.
• Friday. Hell leave me.

• RATIONAL REPLIES
• Whats the error? I cant read his mind or
  foretell the future.
• Whats the evidence? He doesnt call as much as
  he used to. However,hes been very busyat work.
• Could I collect more information? I could ask him
  how he thinks our relationship is going.
• Is there another way to look at it? Hes probably
  just busy and couldnt call. Even if he is losing
  interest, however, that doesnt mean hell leave
  me. Maybe we can improve things.
• So what? Even if the worst is true and he did
  leave me, I could survive. Ive been on my own
  before, and even if it was hard at the time, it
  wasnt impossible.
• (Ask the same kinds of questions as those listed
  above, and try to come up with more realistic
  thoughts.)

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MEICHENBAUMS CONSTRUCTIVIST COGNITIVE-BEHAVIORAL
TREATMENT MODEL

• Donald Meichenbaum has developed several
  manualized and empirically-supported treatments
  using cognitive-behavioral approaches. His
  approach is partly based on the literature on
  common factors in psychotherapy and his interests
  in the psychotherapy integration movement. The
  following tasks of psychotherapy form the core of
  his constructivist cognitive-behavioral treatment
  approach he also views these as the common
  elements in all successful therapy.
• DEVELOP A THERAPEUTIC ALLIANCE AND HELP CLIENTS
  TELL THEIR STORIES.
• EDUCATE CLIENTS ABOUT THE CLINICAL PROBLEM.
• HELP CLIENTS RECONCEPTUALIZE THEIR PROBLEMS IN
  A MORE HOPEFUL FASHION.
• ENSURE THAT CLIENTS HAVE COPING SKILLS.
• ENCOURAGE CLIENTS TO PERFORM PERSONAL
  EXPERIMENTS.
• ENSURE THAT CLIENTS TAKE CREDIT FOR CHANGES THEY
  HAVE BROUGHT ABOUT.
• CONDUCT RELAPSE PREVENTION.
• The constructivist narrative perspective which
  Meichenbaum adds to traditional cognitive therapy
  is based in a view of people as meaning-making
  agents who construct their own stories to
  explain their lives and experiences. In contrast
  to traditional Cognitive Therapy, Meichenbaums
  approach is less structured, more exploratory,
  and more discovery-oriented. Clients are assisted
  in telling their stories and in creating new
  stories through therapy.

• TASK Using this framework, evaluate the
  therapies studied in this course to determine
  which have these elements in common.

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Prevalence of Schizophrenia

• Varies depending on whether a broad (Bleuler) or
  narrow (Kraepelin, Schneider) definition of the
  disorder is used. (DSM-IV is considered a
  middle-of-the-road compromise).
• Schizophrenia occurs
• worldwide at a lifetime prevalence rate of about
  1 (morbidity risk)
• range 0.2 to 2.0
• equally in males and females
• earlier (at least 5 years) for males than females
• men hospitalized more often and prognosis is
  poorer
• usually in the late teens or early 20s, but as
  late as the 50s

• Schizophrenia and related psychoses were not
  included in the Ontario Health Survey (1990)
  Mental Health Supplement because the sample did
  not identify enough people to permit meaningful
  study.

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TYPES OF DELUSIONSFixed beliefs with no basis in
realityThere are several types of delusions that
are often woven together in a complex and
frightening system of beliefs

• PERSECUTORY delusions
• delusions of BEING CONTROLLED
• THOUGHT BROADCASTING
• THOUGHT INSERTION
• THOUGHT WITHDRAWL
• delusions of GUILT or SIN
• SOMATIC delusions
• GRANDIOSE delusions

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Schizophrenia
Diathesis Stress Model of

• DIATHESES
• Genetic factors
• Physical trauma prenatally or during birth
• Structural abnormalities of the brain
• Abnormalities in neurotransmitter systems
• Psychosis-prone personality

• STRESSORS
• Physical trauma, prenatally or during birth
• Chronic psychological and social stressors and
  environmental hazards associated with urban
  living and poverty
• Family environment with high Expressed Emotion

SCHIZOPHRENIA
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Genetic Factorsand Schizophrenia

• The closer a persons biological relationship to
  someone diagnosed with schizophrenia, the greater
  that persons risk of developing schizophrenia or
  one of the schizophrenia spectrum disorders.
• The evidence is clear on several other points
• Schizophrenia runs or aggregates in families.
• This aggregation is found regardless of the type
  of research methodology (family, adoption or twin
  studies) used or the country in which the study
  is performed.
• In many cases a vulnerability that predisposes a
  person to schizophrenia (scientists dont know
  exactly what) is genetically transmitted.
• Genes alone are not sufficient to account for the
  development of schizophrenia.

• Today, most investigators believe that the
  genetic contribution to the majority of cases of
  schizophrenia is polygenic, meaning that a mosaic
  of different genes act in concert to influence
  the development, probability, and severity of
  schizophrenia.

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PSYCHOSOCIAL FACTORS AND SCHIZOPHRENIAThe two
psychosocial factors receiving the most attention
in the study of schizophrenia are socioeconomic
class and associated stressors and family
environment and family communication patterns.

• Explanations for the disproportionate rate of
  schizophrenia among urban and lower SES groups
  include
• the social drift hypothesis, which suggests
  that, as people develop schizophrenic symptoms,
  they gradually slide down the socioeconomic
  ladder and
• the breeder or social causation hypothesis,
  which suggests that social strains and
  environmental hazards breed schizophrenic
  episodes in vulnerable individuals.

• Many schizophrenic people come from families
  that are socially and economically advantaged.
• Despite suffering psychotic symptoms for years
  on end, many schizophrenics do not drift into
  lives of poverty or marginality.

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The Role of EXPRESSED EMOTION and Schizophrenia

• How do you think you would act if you lived with
  a person who had schizophrenia? Would you feel
  afraid? Would you be a nag? Would you challenge
  the person to become more socially involved or
  would you feel sorry for the person?
• There is a strong relation between a familys
  emotional overinvolvement and the rate at which
  patients suffer relapses of schizophrenia.
• EXPRESSED EMOTION usually involves high levels of
• criticism (You dont do anything but sit in
  front of the TV
• hostility (Im sick and tired of your
  craziness) and
• overinvolvement (Ill go downtown with you so we
  can have time together. or Dont you realize
  how hard I try to help you out?).

• How might EE lead to relapse? Perhaps
  schizophrenics are sensitive to environmental
  stimulation, particularly social criticism, which
  may drive up their levels of psychophysiological
  arousal. Under this heightened arousal, they
  might lose some of their already-impaired ability
  to process information accurately. Result? They
  feel bombarded with negative stimuli, their
  symptoms increase, and soon their condition
  deteriorates into a full-blown episode of
  psychosis. Family stressors involving EE could
  also combine with other life events to heighten
  the risk of relapse.

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ONTARIOS FIRST MENTAL HOSPITAL WAS ESTABLISHED
IN THE OLD YORK (TORONTO) JAIL, IN JANUARY, 1841.
ASYLUMS
EARLY MENTAL HOSPITALS IN ONTARIO

• IT WAS ULTIMATELY ESTABLISHED AS THE NOTORIOUS
  999 ON QUEEN STREET IN 1850.
• OFFICIAL TITLE LUNATIC ASYLUM
• LONDON PSYCHIATRIC HOSPITAL WAS CALLED THE
• IDIOT BRANCH
• ORILLIA PSYCHIATRIC HOSPITAL WAS CALLED THE
• HOSPITAL FOR IDIOTS AND IMBECILES

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ChronicSocial BreakdownSyndrome

• APATHY
• DEPENDENCY
• SOCIAL WITHDRAWL

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Antipsychotic (Neuroleptic) Treatment of
Schizophrenia

• The phenothiazines, the primary treatment for
  schizophrenia,
• relieve positive symptoms for 60 to 70 of
  patients (however, fewer than 30 respond well
  enough to live in communities entirely on their
  own) and
• cause several kinds of serious side effects
  (e.g., extra-pyramidal symptoms such as
  Parkinsonism, tardive dyskinesia, and neuroleptic
  malignant syndrome)
• Newer, atypical antipsychotic drugs (e.g.,
  clozapine)
• relieve negative symptoms as well as positive
  symptoms and
• help some patients who are resistant to the
  phenothiazines.

• It is a mistake in my view to think about the
  treatment of schizophrenia in purely biological
  terms. Drugs are usually necessary for
  controlling symptoms, but they cannot make a new
  life for patients or teach them to cope with the
  negative consequences of the disorder.

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Psychosocial Treatment

• The most effective psychosocial treatments for
  schizophrenia focus on
• training in self-help and social skills
• family therapy in which families are taught how
  to deal with patients when they return home
• psychosocial rehabilitation that helps patients
  live in communities by strengthening their
  independent living skills and creating more
  supportive environments
• vocational rehabilitation
• The very best programs also include
• individual case managers who serve as advocates
  and help patients obtain necessary services
• social support that wraps around patients and
  holds them in the community
• peer support groups
• safe houses
• individualized plans to help clients avoid or
  manage crises
• patients help write proactive crisis plan
• specific vocational rehabilitation plan
  identifying occupational goals and needed skills
• job clubs or transitional employment
• interpersonal work skills

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Prevention?Stopping Relapse in Young
Schizophrenic Patients

• Although scientists have discovered no effective
  ways to prevent schizophrenia, psychosocial
  rehabilitation coupled with regular medication
  comes the closest to constituting a form of
  secondary prevention.
• Many programs pay special attention to serving
  relatively young schizophrenic patients who are
  not yet chronically disabled from the disorder.

• The search for more effective treatment must
  include the pursuit of new medications and the
  discovery of how psychosocial and cultural
  stressors and buffers can be changed to lessen
  the incidence of schizophrenia.

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True reform is up to all of usBy Scott
Simmie, The Toronto Star, October 10, 1998

• MONEY
• HOUSING
• COMMUNITY MENTAL HEALTH CENTRES
• PROVINCIAL PSYCHIATRIC HOSPITALS
• RISK ASSESSMENT
• DIVERSION PROGRAMS
• COMMUNITY TREATMENT ORDERS
• BEST DRUGS FIRST
• KIDS--A CLEAR PRIORITY
• CRISIS CENTRES--A PLACE TO GO
• CRISIS LINES--A PLACE TO CALL

• ALTERNATIVE BUSINESSES
• INCOME SUPPORTS
• DRUG COVERAGE EXTENSION
• THE DOCTORS
• ANTI-STIGMA CAMPAIGN
• THE AGENCIES
• EMPLOYERS
• CONSUMERS
• THE POLICE
• THE MEDIA
• BUILDING A SYSTEM
• THE PUBLIC