Psychological Disorders and Treatments Marshall High School Mr. Cline Psychology Unit Five AE
* Therapy We usually think of medicine as intended to cure specific physical symptoms; painkillers to help a headache, antibiotics to cure an infection like strep throat. So how can drugs be designed to affect the mind, achieving specific results like making someone less depressed, or getting rid of hallucinations? Like many medicines, the earliest kinds of psychiatric medications were discovered largely by accident. The first antidepressants were intended as treatments for tuberculosis; the first antipsychotics were developed as anesthetics to use during surgery. These medications were found to improve mental functioning by changing brain chemistry in a variety of ways. In general, they change levels of neurotransmitters in the brain. Neurotransmitters are chemicals in the brain that allow brain cells, called neurons, to communicate with each other.
* Therapy Psychologists have noticed that the amounts of certain neurotransmitters in the brains of people with certain disorders are different than in healthy people's brains, leading to the development of drugs that aim to correct these imbalances. Antidepressants change the levels of the neurotransmitters norepinephrine and serotonin which affect emotion and mood. There are three basic kinds of antidepressants, called MAOIs (Monoamine Oxidase Inhibitors), tricyclics and SSRI's (Selective Serotonin Reuptake Inhibitors). They all function a little differently. MAOIs and tricyclics raise BOTH norepinephrine AND serotonin levels. SSRIs raise ONLY the levels of serotonin in the brain.
* Therapy This creates fewer side effects than MAOIs or tricyclics, though it does increase sexual side effects like lack of desire and erectile dysfunction. MAOIs have the worst side effects, which is why scientists kept working to make the newer kinds of antidepressants. People who take them must be careful to avoid foods that contain the chemical tyramine. Can you guess what kinds of foods contain tyramine? THE BEST KINDS - beer, some cheeses, cured meats. And if a person messes up and eats these foods anyway, it can produce a fatal interaction with the MAOI.
* Therapy These drugs are usually only recommended to people whose bodies can't tolerate the newer antidepressants. While antidepressants work primarily on norepinephrine and serotonin, antipsychotics work by reducing the activity of a third neurotransmitter, called dopamine. Dopamine is the neurotransmitter that regulates pleasure-seeking behavior. You know that rush you get when you get an unexpected reward? Maybe you win at the slot machine, or your boss tells you she's decided to give you a bonus? You feel great because your dopamine levels have spiked.
* Therapy But consistently high levels of dopamine can make you really sensitive to excess stimulation, and in the case of schizophrenics this can cause hallucinations and delusions, known as the positive symptoms of schizophrenia. Antipsychotics can help reduce these 'positive' symptoms, called positive NOT because they are 'good,' but because they are things that are 'more' than what most people experience. Most antipsychotics have little effect on the negative symptoms of schizophrenia like blunted emotions and loss of pleasure, but a new generation of drugs called atypical antipsychotics has been shown to have some effect. All antipsychotics can cause side effects like drowsiness, tremors and coordination issues.
* Therapy There is also a very rare, nasty side effect called tardive dyskinesia, which is a permanent neurological condition that causes involuntary movements. This condition persists even after treatment with antipsychotics is stopped. Bipolar disorder is most commonly treated with another type of psychiatric medication, called lithium. If that sounds familiar from chemistry, you're right; it's an element on the periodic table, and when it's used to treat psychological disorder it's given in the form of a 'salt,' or a kind of chemical compound that includes the element. Though it is an effective mood stabilizer, the way it works in the brain is still unclear.
Treatment with lithium also requires careful monitoring, since the active dose is only slightly less than a toxic dose - most medications have a much larger gap between these amounts, making accidental overdoses less common. Lithium has a long history of use as medication; it's believed that the ancient Greeks and Romans used spring water containing lithium to treat manic and depressive disorders. In the early twentieth century, lithium was an ingredient in a beverage still consumed today, then marketed as a hangover cure. There's no lithium in it anymore, but the drink is - have you guessed it yet? - 7UP.! We've gone over three major classes of drugs for three disorders: antidepressants for major depression, antipsychotics for schizophrenia and lithium for bipolar disorders.
These all work by altering brain chemistry, though in the case of lithium the exact mechanism is unknown. These drugs can be really helpful to some patients, though psychologists worry about prescribing them without careful consideration or as a substitute for talk therapy. Since many of the drugs do not keep working after a patient stops treatment, many patients take them for a very long time and such longterm side effects aren't always known. Given these problems, psychiatric medication should be seen as simply one type of therapy, likely to be used alongside other types, and not a beall-and-end-all treatment for psychological disorders. Before psychiatric drugs were developed, psychiatrists sometimes used other biological methods to try to cure or improve their patients' mental health. Therapists understood that changing the body could change the mind, but they didn't have reliable ways of determining targeted biological treatments.
Most of these treatments are either no longer used today, or are used as lastresort options for severe conditions. These psychiatric methods used in the past seem crude compared to today's treatments. But it's worth having at least a basic knowledge of the origin of biological treatments to gain perspective on current treatments and to think about the ethical issues that surround many of these methods. After years working only with talk-therapy approaches based on the teachings of Freud, psychiatrists were eager to have options for treating patients that were distinctly medical. These biological treatments seemed, at least at first, much more cut-and-dry than talking about feelings. However, many medically based treatments were largely ineffective and often cruel--but were pursued, often, because doctors felt like they were really doing something for their patients, rather than just talking to them or putting them in mental institutions to live out their days.
Electroconvulsive Therapy Electroconvulsive therapy, abbreviated ECT, became popular in the 1940's as a treatment for nonresponsive patients of many psychological disorders, including depression and schizophrenia. Technicians used electric shocks to give patients seizures that were intended to help them recover. Seizure treatments had been used before, but had required giving patients certain drugs that were expensive and sometimes caused unpredictable reactions. ECT gained notoriety in the 1970's due to high-profile negative portrayals in movies like One Flew Over the Cuckoo's Nest. The poet Sylvia Plath described ECT: 'By the roots of my hair some god got hold of me. / I sizzled in his blue volts like a desert prophet.'
Electroconvulsive Therapy You might be surprised, after hearing such a scary, painful-sounding description, to know that ECT is still used today in cases of severe depression. Though there are many people who feel ECT affected them negatively, others report that the treatment really did help them where modern antidepressants failed. A common side effect is memory loss; because of this, patients are rarely forced to undergo the treatment and are encouraged to weigh their decision carefully. For some, some memory loss is worth no longer feeling depressed. For others, this tradeoff is unacceptable. Author Ernest Hemingway complained of the treatment: 'Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient '
Electroconvulsive Therapy Insulin Shock Therapy For someone who wrote fiction for a living, the loss of memory was worse than the depression. Another kind of shock therapy, called insulin shock therapy, was used to treat schizophrenia in the 1930's-50's. Patients would receive doses of insulin, a hormone which you may associate with diabetics. The dose would be high enough to put them into a coma. Doctors would carefully monitor the patients' comas, then eventually revive them. Though some studies showed that it helped, usually the patients selected for the treatment were those with the best chances of getting better anyway.
Insulin Shock Therapy Later doctors found that the insulin itself didn't seem to do anything; patients who were put into comas by other means had similar results. Insulin treatment had lots of nasty side effects, including massive weight gain, restlessness, and discomfort between treatments. It fell out of mainstream use by the 1960's, and is no longer practiced today. Psychosurgery A third kind of biological treatment is known as psychosurgery, or the practice of physically altering the human brain in order to bring about psychological results. This is an extreme treatment; imagine if a scrape on your leg were infected, and after trying lots of things to cure you, doctors eventually just decided to amputate it. Psychosurgery is an attempt to remove or disable a 'sick' part of the brain so that overall mental health is improved.
Lobotomy The most well-known type of psychosurgery is the controversial lobotomy, in which the frontal lobes of the brain are removed in an effort to control the violent and unpredictable symptoms of the severely mentally ill. The procedure typically left patients much more docile than before, but without much of their original personality or functioning. Arguments against lobotomies grew after it was graphically portrayed as punishment for a rebellious psychiatric patient in One Flew Over the Cuckoo's Nest. Lobotomies were largely stopped by the 1970's, but other types of psychosurgery are still performed, although rarely. If other treatments have been ineffective, some surgeons, with patient's consent, will target specific brain areas in order to help regulate their emotions.
Treatment Effectiveness If you're sick with a sore throat, it's fairly easy to tell if a particular treatment has helped: your throat stops hurting. If you take antibiotics and you feel better, there is little debate about whether a treatment was effective or not. Even with something more complex, like cancer, there are concrete measures that can be used to determine whether a treatment is working; a tumor might shrink, or the cancer might stop spreading. But with psychological disorders, such clear measures are often unavailable. In some cases, improvement might be obvious. For example, if a woman who was unemployed due to severe depression was able to get a job after attending therapy sessions for a while, therapy could be judged as effective in her case, at least in relation to one symptom of her illness.
Treatment Effectiveness In other cases, even determining whether someone has a mental illness in the first place is difficult; you can imagine, then, how difficult it can be in some cases to tell if a treatment is actually working. Measuring Treatment Effectiveness There are three main ways in which treatment effectiveness is measured: the patient's own impression of wellness, the therapist's impression, and some controlled research studies. Note that in the realm of physical medicine, the first two methods would be largely irrelevant; a doctor wouldn't simply offer an opinion on whether the patient was better, then she'd show real concrete evidence of it. But in the realm of psychology, these methods can be valuable, though flawed, tools for evaluating treatment effectiveness.
Patient's Impressions and Expectations Obviously if a patient feels better, that's great. So in one sense, a patient's impressions are extremely important--the goal of therapy is, after all, to restore her to mental and emotional well-being. But for the purposes of determining which treatments are most effective in which situations, there are several problems with a patient's own impressions of her progress. The first is simply that people in distress tend to get better. This is known as regression to the mean, or average, and it's when people have a tendency to move toward an average level of functioning or happiness from whatever state they are in. If you're really happy, you're most likely to get sadder, and if you're really sad, you're most likely to get happier. People spend most of their time feeling average, so moods that are above or below average are likely to return to this average.
Patient's Impressions and Expectations Since people usually enter treatment because they're feeling especially bad, they're likely to get better over time not because of anything the therapist is doing, but simply because they're regressing to the mean. Secondly, people in therapy expect to get better. You might have heard of the placebo effect? For a quick summary, imagine you have a headache: what do you usually do to fix it? Let's say you take aspirin or some other painkiller, and usually the headache goes away. You expect that when you take aspirin, your head will feel better. Now let's say your friend, playing a practical joke on you, secretly replaces your aspirin with similar-looking sugar pills.
Patient's Impressions and Expectations The placebo effect predicts that when you take these sugar pills for your headache, you will still feel at least a little better because you expect to; some of the effect of the painkiller is that you think you'll get better when you take one. This is especially true of therapy's effect on mental illness, since the symptoms are often much more subjective than a headache to begin with. If patients expect to get better, they probably will, at least in some ways. On a related note, patients sometimes feel like they should be getting better as a way of justifying the effort involved in seeking treatment; going to see the therapist, paying money for sessions or for drugs. It would be difficult to put in this kind of effort while thinking it was all worthless; therefore, some patients decide to believe in treatment.
Shortcomings of Therapist's Evaluations Therapists' evaluations of patients are subject to all of the same problems as patients' evaluations. They, too, may mistake regression to the mean for positive effects of treatment. They also rely on patient testimony to a certain extent, which may be influenced by the placebo effect or by the justification of effort. Additionally, when therapy is finished, the therapist may continue to hear from patients who are doing well, but not from patients who are dissatisfied; because therapists are reminded only of the positive results, they overestimate how often their patients have positive results. This is known as the availability heuristic.