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

1. 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

2. 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 clinician’s conceptual approach to a person’s problem will determine the selection of assessment instruments. This figure lists examples of variables that might be considered within each broad conceptual level.

3. 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 clinician’s conceptual approach to a person’s problem will determine the selection of assessment instruments. This figure lists examples of variables that might be considered within each broad conceptual level.

4. Clinical psychologists typically employ three primary modes of assessment: INTERVIEWS: gather information from the person’s point of view. TESTS:can be “objective” or “projective. DIRECT OBSERVATION: may be used as “signs” or “samples” of behavior. Modes of Assessment • 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 therapist’s interview.

5. COGNITIVE-BEHAVIOURAL CASE FORMULATION: PERSONS' APPROACH CASE FORMULATION: The therapist’s hypothesis about the nature of the psychological mechanisms underlying the client’s difficulties DOES THE CASE FORMULATION IMPROVE TREATMENT OUTCOME? DIFFERS FROM BEHAVIOURAL ANALYSIS IN PLACING MUCH MORE EMPHASIS ON UNDERLYING COGNITIONS VIEWS CLIENT’S PROBLEMS AS EXISTING AT TWO LEVELS:  OVERT DIFFICULTIES=the actual problems in living that clients seek help for (e.g., depression, relationship difficulties)  UNDERLYING MECHANISMS=the 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) ? THE MODEL

6. CLINICAL APPLICATION OF THE PERSONS CASE FORMULATION MODEL 1. PROBLEM LIST 2. DIAGNOSIS 3. WORKING HYPOTHESIS 4. STRENGTHS & ASSETS 5. TREATMENT PLAN

7. 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?

8. 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 How Does a Therapist Differ From a Friend?

9. 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 PODDAR’S THERAPIST (A CLINICAL PSYCHOLOGIST AT THE UNIVERSITY OF CALIFORNIA AT BERKELEY) SHOULD HAVE WARNED TARASOFF THAT HER LIFE MIGHT BE IN DANGER.

10. Psychoanalysis FREUD’S 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

11. 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

12. Shopping malls Cars Trains Buses Subways Wide streets Tunnels Restaurants Theatres Supermarkets Stores Crowds Planes Elevators Escalators Waiting in line Being far from home Typical Situations Avoided by a Person with Agoraphobia

13. 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

14. 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

15. 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

16. 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

17. 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 • SSRI’s, high potency benzodiazepines, TCA’s **Variation: individual vs. group

18. 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)

19. 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

20. 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

21. Shopping malls Cars Trains Buses Subways Wide streets Tunnels Restaurants Theatres Supermarkets Stores Crowds Planes Elevators Escalators Waiting in line Being far from home Typical Situations Avoided by a Person with Agoraphobia

22. EVENT AUTOMATIC NEGATIVE THOUGHTS My boyfriend He’s losing interest didn’t call on in me. Friday. He’ll leave me. I feel rejected. It means I’m undesirable. No one will ever love me. I’ll always be alone. RATIONAL REPLIES What’s the error? I can’t read his mind or foretell the future. What’s the evidence? He doesn’t call as much as he used to. However,he’s 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? He’s probably just busy and couldn’t call. Even if he is losing interest, however, that doesn’t mean he’ll leave me. Maybe we can improve things. So what? Even if the worst is true and he did leave me, I could survive. I’ve been on my own before, and even if it was hard at the time, it wasn’t impossible. (Ask the same kinds of questions as those listed above, and try to come up with more realistic thoughts.) Beck’s Cognitive- Behavioral Therapy:Three-Column Technique

23. 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, Meichenbaum’s 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. MEICHENBAUM’S CONSTRUCTIVIST COGNITIVE-BEHAVIORAL TREATMENT MODEL

24. 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. Prevalenceof Schizophrenia

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

26. 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 Diathesis Stress Model of Schizophrenia SCHIZOPHRENIA

27. The closer a person’s biological relationship to someone diagnosed with schizophrenia, the greater that person’s 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 don’t 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. Genetic Factorsand Schizophrenia

28. 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. 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.

29. 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 family’s emotional overinvolvement and the rate at which patients suffer relapses of schizophrenia. EXPRESSED EMOTION usually involves high levels of criticism (“You don”t do anything but sit in front of the TV” hostility (“I’m sick and tired of your craziness”) and overinvolvement(“I’ll go downtown with you so we can have time together.” or “Don’t 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. The Role of “EXPRESSED EMOTION” and Schizophrenia

30. ASYLUMS ONTARIO’S FIRST MENTAL HOSPITAL WAS ESTABLISHED IN THE OLD YORK (TORONTO) JAIL, IN JANUARY, 1841. 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”

31. ChronicSocial BreakdownSyndrome • APATHY • DEPENDENCY • SOCIAL WITHDRAWL

32. 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. Antipsychotic (Neuroleptic) Treatment of Schizophrenia

33. 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 Psychosocial Treatment

34. 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. Prevention?Stopping Relapse in Young Schizophrenic Patients

35. True reform is up to all of us”By 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