Chapter 14: Approaches to Treatment and Therapy

Biological Treatments for Mental Disorders

“Medication” vs. “drug”: medication is used to treat illness or disorder, whereas drugs can be taken for medical treatment but also other reasons (i.e. recreational use).
Most common biological treatment for mental disorders is medication that alters production or response to neurotransmitters.
Four main classes of medications used to treat mental disorders:
1. Antipsychotics: for schizophrenia and other psychoses
  - Block sensitivity of brain receptors to dopamine or serotonin.
  - Can cause emotional flatness or apathy.
2. Antidepressants: for depression, anxiety, phobias, and OCD.
  - Prevent re-uptake of norepinephrine and serotonin.
  - Often have side effects.
  - Stopping taking them abruptly can cause withdrawals.
3. Anti-anxiety medications (tranquilizers): temporarily help with acute anxiety attacks, but are not long-term treatments.
  - A significant number of people overuse them and develop higher tolerance.
4. Mood stabilizers: for bipolar disorder.
Electroconvulsive therapy (ECT): “shock therapy” that triggers a seizure; can treat crippling major depression or suicidal thinking.
- Safe and effective treatment, but has a problematic public image.

Journals tend to publish positive findings, and not negative or neutral ones.
Placebo effect
Side effects and medication discontinuation.
- Side effects cause people to stop taking medication, which causes relapse.
- Side effects might be caused by patients being given incorrect dosages.
Disregard for effective, possibly better non-medical treatments
- Managed-care organizations prefer to pay for one patient visit for a prescription rather than 10 visits for psychotherapy.
Unknown risks over time and medication interactions
Untested off-label uses
- After a medication is FDA approved, doctors can prescribe it for other conditions/populations.

Originate from Freud’s psychoanalytic methods.
Involve delving into deep, unconscious processes.
Transference: the client’s displacement of emotional elements of their inner life (usually feelings about parents) onto someone.

Behavior therapy: based on principles of classical operant conditioning. Four methods:
1. Behavioral self-monitoring: identify reinforcers that are supporting behaviors.
  - Keep a behavioral record of when the behavior occurs.
2. Exposure
  - Graduated exposure: exposure treatments with a source of fear.
  - Flooding: therapist takes client directly into the feared situation, and remains there until the client’s fear and distress decline.
3. Systematic desensitization
  - Similar to exposure, but involves relaxation during the exposure.
  - Based on classical-conditioning procedure of counterconditioning.
4. Skills training: teaching a client skills they lack through operant-conditioning techniques, modeling, and role-playing.
Cognitive therapy: using constructive thinking to reduce anger, fear, and depression.
- Clients learn to consider other explanations for the behavior of people who annoy them.
- Rational emotive behavior therapy (REBT): the therapist uses rational arguments to directly challenge a client’s unrealistic beliefs or expectations.
Cognitive-Behavioral Therapy (CBT): a combination of cognitive and behavioral therapy.

Humanist therapy: therapist learns how clients subjectively see their own situations and the world around them.
Client-centered (nondirective) therapy): therapist listens to the client’s needs and offers unconditional positive regard.
- Client will eventually internalize the therapist’s support and become more self-accepting.
Existential therapy: helps clients face death, freedom, loneliness, and meaninglessness.

Family therapists maintain that problems develop in the context of family. Changes to one member affect other members.
- Family-systems perspective: therapy approach that emphasizes identifying how each family member forms a part of a larger family system.

Scientist-practitioner gap: a gap between therapists who don’t think their practices can be fairly evaluated with sciences, and scientists who think therapists need to pay more attention to empirical scientific findings.
- One explanation: professional schools that only teach therapy, and not much about research methods.
Critical incident stress debriefing (CISD): debriefing survivors after a traumatic event. It has been shown to not be helpful, and to delay recovery.
CBT has been effective for:
- Depression
- Suicide attempts
- Anxiety disorders
- Anger and impulsive violence
- Health problems
- Childhood and adolescent behavior problems
- Relapses
Family interventions can also contribute to better recovery.
Multisystemic therapy: treating neighborhood (local leaders, parents, teachers, etc) using family-systems techniques.
When clients and psychotherapists are culturally matched, they likely share perceptions of what the client’s problem is, agree on the best way of coping, and have the same expectations about what therapy can accomplish.

Medications
- Antipsychotic medications
  - Old (“neuroleptics”)
    - Motor side effects
  - New (“atypical”)
    - Less motor side effects
  - How do they work?
    - Block dopamine post-synaptic receptors
      - See: Dopamine Hypothesis of Schizophrenia
    - Negative symptoms, caused by too little dopamine activity in another pathway in the brain, get worse.
    - Another dopamine pathway is also suppressed, which causes the motor side effects.
Brain Stimulation Techniques
- Stimulation of left frontal cortex improves negative symptoms

Medications
- Anti-depressants
  - Tricyclics
    - Prevent reuptake of serotonin and norepinephrine
  - Serotonin reuptake inhibitors (SRIs)
    - Prevent reuptake of serotonin
  - Monoamine oxidase (MAO) inhibitors
    - Prevent MAO from breaking down serotonin and norepinephrine
  - Ketamine
    - Given by infusion
    - Rapid burst of glutamate (excitatory), and new synapses form as a result
    - Works differently than the other 3
- Significant improvement, but usually takes several weeks to see
  - Side effects unfortunately show up faster
Electroconvulsive Theory (ECT)
- Induce seizure via electrical current through brain
  - Mechanism of action is unclear
  - Seizures are complicated and a lot of things happen
- Only for very ill patients, or patients non-responsive to other treatments
- Can cause short-term memory loss (for events before + after treatment)
Transcranial magnetic stimulation
- Use magnet to stimulate part of brain that regulates mood
Deep brain stimulation
- Requires surgery and implant
Cognitive Behavioral Therapy (CBT)
- Corrects faulty thinking and distortions
- As effective as medication
  - Can have longer-lasting effects

Medications
- Antidepressants
  - Same as for depression, but in higher doses
Behavior therapy
- Exposure therapy
  1. Expose patient to stimulus
  2. Prevent response
Transcranial magnetic stimulation (TMS)
Neurosurgery
- Try this after other things
- Destroys a part of the brain
  - Interrupts signals to frontal cortex from caudate
Gamma knife
- Uses radiation to create lesions inside of brain without invasive surgery