Gazzaniga • Heatherton • Halpern Psychological Science FOURTH EDITION Chapter 15 Treatment of Psychological Disorders ©2013 W. W. Norton & Company, Inc. 15.1 How Are Psychological Disorders Treated? • Distinguish between forms of psychotherapy. • Describe the major categories of psychotropic drugs. • Identify alternative biological treatments for mental disorders. • Distinguish between specialized mental health practitioners. How Are Psychological Disorders Treated? • Psychological disorders need to be managed over time through treatment • Treatment depends on the type and severity of symptoms as well as on the diagnosis • Most mental disorders can be treated in more than one way • Psychologists use two basic categories of techniques to treat mental disorders: psychological and biological Psychotherapy Is Based on Psychological Principles • Psychotherapy generally is aimed at changing patterns of thought or of behavior • It has been estimated that there are more than 400 approaches to treatment • Many therapists follow an eclectic approach and use a variety of techniques • The relationship between the therapist and the client is known to affect the outcome of therapy Psychodynamic Therapy Focuses on Insight • Freud and Breuer pioneered the method of psychoanalysis – Treatment involved uncovering unconscious feelings and drives that gave rise to maladaptive thoughts and behaviors – Techniques included free association and dream analysis – General goal of psychoanalysis is to help clients gain insight into their unconscious and how these processes affect daily functioning, thus freeing them from these unconscious influences • Contemporary therapists examine patients’ needs, defenses, and motives as a way of understanding why they’re distressed • Psychodynamic therapy has become increasingly controversial (expensive, time consuming, scant evidence of effectiveness) • Proponents argue that this short-term psychodynamic therapy can be useful for treating certain disorders Health Benefits of Talking and Expressing Emotions • Researchers have found positive health effects for people who disclose emotional events – College students who were randomly assigned to write about an emotional event visited the university health center fewer times than students assigned to write about other topics, even though there were no group differences in how often the students visited the health center before participating in the study (Pennebaker & Beall, 1986). • Talking or writing about emotionally charged events reduces blood pressure, muscle tension, and skin conduction during the disclosure and immediately thereafter • Improves immune function, even in people with HIV Humanistic Therapies Focus on the Whole Person • The goal of humanistic therapy is to treat the person as a whole, not as a collection of behaviors or a repository of repressed thoughts • Client-centered therapy encourages people to fulfill their individual potentials for personal growth through greater selfunderstanding – Therapists strive to create a safe and comforting setting for clients to access their true feelings, to be empathic and to accept the client through unconditional positive regard – Therapist will use reflective listening, in which the therapist repeats the client’s concerns to help the person clarify his or her feelings • Motivational interviewing has proven to be a valuable treatment for drug and alcohol abuse, as well as for increasing both healthy eating habits and exercise (Burke, Arkowitz, & Menchola, 2003) Cognitive and Behavioral Therapies Target Thoughts and Behaviors • Behavior therapy: Behavior is learned and therefore can be unlearned through the use of classical and operant conditioning – Social skills training: Client learns appropriate ways to act in specific social situations – Learn through modeling • Cognitive therapy: Distorted thoughts produce maladaptive behaviors and emotions; treatment strategies attempt to modify these thought patterns • Forms: – Cognitive restructuring – Rational-emotive therapy – Mindfulness-based therapy – Cognitive Behavioral Therapy (CBT) “Cognitive Behavioral Therapy” While neuroscientists look for the cause of schizophrenia in the brain, psychologists are looking for ways other than medication to help people make sense of and deal with the voices they hear. And as this ScienCentral News video reports, a therapy adopted in Britain seems to have the answer. Group Therapy Builds Social Support • Group therapy rose in popularity after World War II • There were many different stresses related to the war, with more people needing therapy than there were therapists available to treat them • Advantages: – Group therapy is often significantly less expensive than individual treatment – Group setting provides an opportunity for members to improve their social skills and learn from one another’s experiences • Many groups are organized around a particular type of problem (e.g., sexual abuse) or around a particular type of client (e.g., adolescents). Therapy may be highly structured, or a more loosely organized forum for discussion. Family Therapy Focuses on the Family Context • According to a systems approach, an individual is part of a larger context where changes in individual behavior will affect the whole system • Some therapists insist that family members be involved in therapy, where all family members involved in therapy are considered as the client – Example: A child’s defiant behavior has led to conflict between parents. Treatment involves not only working on the child’s behavior, but also helping the parents learn to resolve their conflict • The level of expressed emotion from family members corresponds to the relapse rate for patients with schizophrenia (Hooley & Gotlib, 2000) Culture Can Affect the Therapeutic Process • Culture has multiple influences on the way psychological disorders are expressed, which people with psychological disorders are likely to recover, and people’s willingness to seek help – Many Chinese distrust emotional expression and avoid seeking help for depression, anger, or grief (Magnier, 2008) – In India, a corps of health counselors was trained to screen for psychological disorders but because of the cultural stigma of mental disorders, terms such as mental illness, depression, and anxiety were avoided; terms such as tension and strain were used instead (Kohn, 2008) • Culture plays a critical role in determining the availability, use, and effectiveness of different types of psychotherapy for various cultural and ethnic groups living within any country Medication Is Effective for Certain Disorders • Drugs that affect mental processes are called psychotropic medications • Anti-anxiety drugs: used for the treatment of anxiety – One class of anti-anxiety drugs is benzodiazepines – Increase the activity of GABA – Induce drowsiness and are highly addictive • Antidepressants: used for the treatment of depression – Monoamine oxidase (MAO) inhibitors – Tricyclics – Selective serotonin reuptake inhibitors (SSRI) • Antipsychotic/neuroleptics Alternative Biological Treatments Are Used in Extreme Cases • Treatment-resistant people cannot be treated successfully with psychotherapy, medication, or both combined • Alternative treatments include: brain surgery, the use of magnetic fields, and electrical stimulation • Many early efforts reflected crude attempts to control disruptive behavior: – Trepanning – Psychosurgery (prefrontal lobotomy) Electroconvulsive Therapy • Electroconvulsive therapy (ECT): a procedure that involves administering a strong electrical current to the patient’s brain to produce a seizure • Effective for some cases of severe depression • The procedure was developed in Europe in the 1930s and tried on the first human in 1938; commonly used in the 1950s and 1960s to treat some psychological disorders • The general public has a very negative view of ECT • ECT now generally occurs under anesthesia, with powerful muscle relaxants to eliminate motor convulsions and confine the seizure to the brain Transcranial Magnetic Stimulation • During transcranial magnetic stimulation (TMS), a powerful electrical current produces a magnetic field (about 40,000 times Earth’s magnetic field) • When rapidly switched on and off, this magnetic field induces an electrical current in the brain region directly below the coil, thereby interrupting neural function in that region – Single-pulse TMS: Disruption of brain activity occurs only during the brief period of stimulation – Repeated TMS: Multiple pulses of TMS occur over extended period • TMS may be useful for depression Deep Brain Stimulation • Deep brain stimulation (DBS): Electrodes are surgically implanted deep within the brain; mild electricity is then used to stimulate the brain at an optimal frequency and intensity • DBS has been tremendously successful in treating Parkinson’s disease • DBS is being tested for treating other disorders, including mental disorders such as severe OCD and depression Therapies Not Supported by Scientific Evidence Can Be Dangerous • Most psychologists recommend treatments that careful empirical research has shown to be effective • Unfortunately, many available therapies have no scientific basis, including ones in which people re-enact their own births, scream, or have their body parts manipulated • Some treatments believed to be effective are counterproductive: – Encouraging people to describe their experiences following major trauma – Scaring adolescents away from committing crimes – Having police officers run drug education programs such as DARE – Using hypnosis to recover painful memories • These methods not only lack adequate evidence but also may produce results opposite to those intended (Hines, 2003; Lilienfeld, 2007) A Variety of Providers Can Assist in Treatment for Psychological Disorders • Providers range from those with limited training (e.g., former addicts who provide peer counseling) to those with advanced degrees in psychopathology • Most therapeutic techniques used have emerged from psychological laboratories • Choosing the right therapist is difficult but extremely important for ensuring successful treatment • One of the central problems with treating psychological disorders is that there simply are not enough people available to provide traditional one-on-one psychotherapy to all who need it • Technology-based treatments “’Tongue Mouse’ Can Control a Wheelchair or Computer” Imagine changing channels or surfing the Web with just a flick of your tongue. Researchers have developed such a device. As this ScienCentral News video shows, the system holds the most promise for those who are paralyzed. 15.2 What Are the Most Effective Treatments? • Identify the treatments that are most effective for specific psychological disorders. What Are the Most Effective Treatments? • Certain types of treatments are particularly effective for specific types of mental disorders • Scientific studies of treatment indicate that although some mental disorders are quite easily treated, others are not: – Highly effective treatments exist for anxiety disorders, mood disorders, and sexual dysfunction – Few treatments for alcoholism are superior to the natural course of recovery that many people undergo without psychological treatment • People often resolve personal problems on their own without psychological treatment • Because people tend to enter therapy when they experience crises, they often show improvements no matter what therapy they receive Effectiveness of Treatment Is Determined by Empirical Evidence • The only way to know whether a treatment is valid is to conduct empirical research that compares the treatment with a control condition • Randomized clinical trials can establish whether a particular treatment is effective • Findings from medical studies often lead to dramatic changes in treatment practice • Such developments reflect the increasing importance of evidence-based treatments “Alzheimer’s Smell Test” A simple scratch-and-sniff test could flag the first signs of Alzheimer’s disease. As this ScienCentral News video reports, the memory researcher who’s developing the test hopes to give doctors a jump on curtailing the devastation. Treatments That Focus on Behavior and on Cognition Are Superior for Anxiety Disorders • Treatment approaches to anxiety disorders have had mixed success: – Psychoanalytic theory did not prove useful for treating anxiety disorders – Evidence suggests that cognitive-behavioral therapy works best to treat most adult anxiety disorders (Hofmann & Smits, 2008) – Anxiety-reducing drugs are also beneficial in some cases • Drug effects may be limited to the period during which the drug is taken, whereas the effects of cognitive-behavioral therapy persist long after treatment Specific Phobias • Most phobias develop in the absence of any particular precipitating event • Learning theory cannot completely explain the development of phobias; behavioral techniques are the treatment of choice – One method used is systematic desensitization – To expose clients without putting them in danger, practitioners may use virtual environments • Some cognitive strategies have also proven useful for the treatment of phobia – Brain-imaging data indicate that successful treatment with cognitive-behavioral therapy alters the way the brain processes the fear stimulus • Pharmacological treatments for phobias sometimes include tranquilizers, which can help people handle immediate fears Panic Disorder • Panic disorder has multiple components, and each symptom may require a different treatment • In the treatment of panic attacks, cognitive-behavioral therapy appears to be as effective as or more effective than medication (Schmidt & Keough, 2011) • Methods for treating panic disorder include: – Cognitive restructuring addresses ways of reacting to the symptoms of a panic attack; helps clients recognize the irrationality of their fears – Breaking the connection between the trigger symptom and the resulting panic through exposure treatment Obsessive-Compulsive Disorder • Traditional anti-anxiety drugs are completely ineffective for OCD • The drug of choice for OCD is clomipramine, a potent serotonin reuptake inhibitor (SSRI) • Cognitive-behavioral therapy is also effective for OCD • The two most important components of behavioral therapy for OCD are exposure and response prevention • There is evidence that adding CBT to SSRI improves treatment outcomes; many practitioners recommend the combination of these treatments (Franklin & Foa, 2011) • Deep brain stimulation (DBS) may be an effective treatment for those with OCD who have not found relief from CBT or medication. Many Effective Treatments Are Available for Depression • Depression is one of the most widespread mental disorders among adolescents and adults, and it has become more common over the past few decades • Scientific research has validated a number of effective treatments, but there is no “best” way to treat depression • Ongoing research is being done to determine which type of therapy works best for which types of individuals Pharmacological Treatment • MAO inhibitors are effective but are generally reserved for patients who do not respond to other antidepressants • Tricyclics are extremely effective antidepressants, but they have a number of unpleasant side effects • SSRIs are prescribed most frequently because they have fewer serious side effects than MAO inhibitors and tricyclics • Physicians often must resort to a trial-and-error approach in treating patients who are experiencing depression as no single drug stands out as being most effective Questions About Pharmacological Treatment • Antidepressants may help treat the symptoms of depression without having any influence on the underlying cause • Placebo treatments appear to be associated with changes in neurochemistry and do alleviate symptoms for some people • Only drug trials that involve individuals with severe depression show clear benefits of drugs over placebos, in part because people with severe depression show less response to placebo treatments (Kirsch et al., 2008) • Both drugs and placebos help people who are suffering from depression Cognitive-Behavioral Treatment • Not all patients benefit from antidepressant medications and some patients cannot or will not tolerate the side effects • Cognitive-behavioral therapy is just as effective as antidepressants in treating depression (Hollon et al., 2002) • Cognitive-behavioral therapy can be effective on its own, but combining it with antidepressant medication can be more effective than either one of these approaches alone (McCullough, 2000) Alternative Treatments • In patients with Seasonal Affective Disorder ((SAD)/winter blues), episodes of depression are most likely to occur during winter, with the rate of these disorders increasing with latitude – Many of these patients respond favorably to phototherapy, which involves exposure to a high-intensity light source for part of each day • For some patients with depression, regular aerobic exercise can reduce the symptoms and prevent recurrence • Electroconvulsive therapy (ECT) is a very effective treatment for those who are severely depressed and do not respond to conventional treatments • Transcranial magnetic stimulation (TMS) over the left frontal region results in a significant reduction in depression “Winter Mood” The cold, dark days of winter are known to lower the spirits of many people. Now scientists have a new therapy that can make you feel like spring is in the air. This ScienCentral News video has more. Deep Brain Stimulation • DBS might be valuable for treating severe depression when all other treatments have failed • Several studies have been done of using DBS for treatment-resistant depression, and each time at least half of the clients benefited from this treatment. Some of them felt relief as soon as the switch was turned on Gender Issues in Treating Depression • Women are twice as likely to be diagnosed with depression as men • The APA published Guidelines for Psychological Practice with Girls and Women (2007) to build awareness of gender-specific stressors • Men are reluctant to admit to depression and to seek appropriate therapy • This has been described as “a conspiracy of silence that has long surrounded depression in men” (Brody, 1997) • One goal is to help men stop masking their depression with alcohol, isolation, and irritability “Undoing Depression” You can train dogs to bark or sit. But what about training mice to grow new brain cells? A Nobel Prize-winning scientist has done that, and he says it could lead to new ways to treat depression in people. Lithium Is Most Effective for Bipolar Disorder • Bipolar disorder is one of the few mental disorders for which there is a clear optimal treatment: psychotropic medications, especially the mood stabilizer lithium • Lithium seems to modulate neurotransmitter levels, balancing excitatory and inhibitory activities (Jope, 1999) • Lithium has unpleasant side effects including thirst, hand tremors, excessive urination, and memory problems • Lithium works better on mania than on depression; patients often are treated with both lithium and an antidepressant • Patient compliance with drug therapy can be a problem Pharmacological Treatments Are Superior for Schizophrenia • Historically, psychotic patients were often institutionalized in large mental hospitals • Brain surgery, such as prefrontal lobotomy, was considered a viable option for patients with severe mental disorders but was ineffective in treating people with schizophrenia • The introduction of psychotropic medications in the 1950s eliminated the use of lobotomy Pharmacological Treatments • Chlorpromazine and haloperidol revolutionized the treatment of schizophrenia and became the most frequently used treatments for this disorder – Chlorpromazine: acts as a major tranquilizer, reduces anxiety, sedates without inducing sleep, decreases the severity and frequency of the positive symptoms – Haloperidol: is chemically different and has less of a sedating effect than chlorpromazine – These have little or no impact on the negative symptoms of schizophrenia and have significant side effects • Second-generation antipsychotics such as Clozapine, Risperdol, and Zyprexa are more effective and also have fewer side effects Psychosocial Treatments • Medication effectively reduces delusions and hallucinations but does not substantially improve patients’ social functioning • Social skills training is an effective way to address some deficits in patients • When self-care skills are deficient, behavioral interventions can focus on areas such as grooming and bathing, management of medications, and financial planning • Initial studies using CBT for schizophrenia indicate that it is more effective than other psychological treatments in reducing symptoms such as delusions and hallucinations Prognosis In Schizophrenia • It is in the best interest of patients with schizophrenia to treat the disorder early and aggressively • Most patients with schizophrenia improve over time. – One long-term study that followed participants for an average of 32 years showed that between half and two-thirds were recovered or had experienced considerable improvement in functioning on follow-up (Harding, Zubin, & Strauss, 1987) • The prognosis depends on factors that include age of onset, gender, and culture 15.3 Can Personality Disorders Be Treated? • Discuss therapeutic approaches for borderline personality disorder and antisocial personality disorder. Can Personality Disorders Be Treated? • Little is known about how best to treat personality disorders as very few large, wellcontrolled studies have been undertaken • Most therapists agree that personality disorders are notoriously difficult to treat • Patients see the environment rather than their own behavior as the cause of their problems, which makes them very difficult to engage in therapy Dialectical Behavior Therapy Is Most Successful for Borderline Personality Disorder • Marsha Linehan’s dialectical behavior therapy (DBT) is the most successful in treating persons with borderline personality disorder • Combines elements of behavioral and cognitive treatments with a mindfulness approach based on Eastern meditative practices and proceeds in three stages: – First, the patient’s most extreme and dysfunctional behaviors are targeted with a focus on replacing them with more appropriate ones – Second, the therapist helps the patient explore past traumatic experiences that may be at the root of emotional problems – Third, the therapist helps the patient develop self-respect and independent problem solving Antisocial Personality Disorder Is Extremely Difficult to Treat • Treating those with antisocial personality disorder often seems impossible • Patients lie without thinking twice about it, care little for other people’s feelings, and live for the present without consideration of the future • Patients are often more interested in manipulating therapists than in changing their own behavior, which means therapists must be constantly on guard Therapeutic Approaches for Antisocial Personality Disorder • Psychotropic medications have not been effective in treating this disorder • Traditional psychotherapeutic approaches are of little use, whereas behavioral and cognitive approaches have had somewhat more success • Therapy for this disorder is most effective in a residential treatment center or a correctional facility Prognosis for Antisocial Personality Disorder • The prognosis that patients with antisocial personality disorder will change their behaviors as a result of therapy is poor, particularly for patients with psychopathic traits • Fortunately for society, individuals with antisocial personality disorder but without psychopathy typically improve after age 40 • Conduct disorder is a childhood condition known to be a precursor to antisocial personality disorder • Time and effort may be better spent in prevention than in treatment 15.4 How Should Childhood Disorders and Adolescent Disorders Be Treated? • Discuss the current controversy regarding the use of drugs to treat depression among adolescents • Identify drugs and behavioral treatments for ADHD • Describe applied behavioral analysis • Discuss the use of oxytocin in the treatment of autism How Should Childhood Disorders and Adolescent Disorders Be Treated? • In the United States, an estimated 12 percent to 20 percent of children and adolescents suffer from mental disorders • Problems not addressed during childhood or adolescence may persist into adulthood • Children and adolescents are more malleable than adults and more amenable to treatment • Childhood and adolescent disorders should be the focus of research into etiology, prevention, and treatment The Use of Medication to Treat Adolescent Depression Is Controversial • Approximately 8 percent of the U.S. population, ages 12 to 17, reported experiencing within the last year a major depressive episode that met DSM criteria (SAMHSA, 2011) • About one-third of adolescents with psychological disorders receive any form of treatment; the percentage is even lower for adolescents from racial and ethnic minorities • SSRIs are effective, but increase the risk of suicidal thinking and suicidal behavior in children and adolescents TADS • Treatment for Adolescents with Depression Study (TADS, 2004) provided clear evidence that the SSRI Prozac is effective in treating adolescent depression • The group receiving Prozac and CBT did best (71 percent improved) • Participants in the Prozac group were twice as likely to have serious suicidal thoughts or intentions compared with those undergoing other treatments • Overall, suicide attempts were quite uncommon (7 of 439 patients) Further Thoughts On Treatment Approaches • The main question is: Do the millions of children who take antidepressants experience more benefits than risks? • Suicide rates have dropped since the use of SSRIs became widespread • Not providing SSRIs to adolescents may raise the suicide rate (Brent, 2004) • CBT is most effective but expensive and time-consuming • Prescribing drugs without CBT might be cost-effective (Domino et al., 2008), but it may not be in the best interests of adolescents with depression Children With ADHD Can Benefit from Various Approaches • There is some dispute about whether attention deficit hyperactivity disorder is a mental disorder • Some people diagnosed with ADHD as children grow out of it • Many suffer from the disorder throughout adolescence and are more likely to drop out of school; to reach a lower socioeconomic level than expected; show continued patterns of inattention, of impulsivity, and of hyperactivity; and they are at increased risk for other psychiatric disorders (Wilens, Faraone, & Biederman, 2004) • Effective treatment early in life may be of great importance Pharmacological Treatment of ADHD • The most common treatment for ADHD is a central nervous system stimulant, such as methylphenidate (Ritalin) – Functional brain imaging shows that children with ADHD have underactive brains; their hyperactivity may raise their arousal levels – Studies have shown that children taking Ritalin are happier, more adept socially, and somewhat more successful academically, although the effects on academic performance are modest – The medication has its drawbacks: Side effects include sleep problems, reduced appetite, body twitches, and the temporary suppression of growth • Most therapists believe medication should be supplemented by psychological therapies, such as behavior modification Behavioral Treatment of ADHD • Behavioral treatment of ADHD aims to reinforce positive behaviors and ignore or punish problem behaviors • A recent meta-analysis of 174 studies consisting of over 2,000 research participants found clear support for the effectiveness of behavioral therapy for ADHD (Fabiano et al., 2009) • Many therapists advocate combining behavioral approaches with medication • Studies show that medications may be important in the short term, but psychological treatments may produce superior outcomes that last Children With Autism Benefit from Structured Behavioral Treatment • Core symptoms of autism—impaired communication, restricted interests, and deficits in social interaction— make these children particularly difficult to work with • Normal children respond positively to social praise and small prizes, but children with autism often are oblivious to these rewards; food is sometimes the only effective reinforcement in the initial stages of treatment • Structured therapies are more effective for these children than are unstructured interventions, such as play therapy Behavioral Treatment For Autism • One of the best-known and perhaps most effective treatments for children with autism is applied behavioral analysis (ABA) • ABA is based on principles of operant conditioning: – This very intensive approach requires a minimum of 40 hours of treatment per week – Initiating treatment at a younger age yielded better results, as does involving parents – Research example: Instruction in symbolic play also leads to increased language use, greater parent/child play, and greater creativity in play Biological Treatment For Autism • SSRIs are not helpful for treating the symptoms of autism and actually may increase agitation (McPheeters et al., 2011) • Antipsychotics, such as Risperdal, appear to reduce repetitive behaviors associated with self-stimulation but have side effects (e.g., weight gain) • A deficit in oxytocin may be related to some of the behavioral manifestations of autism; studies show that it may improve functioning in people with autism Prognosis For Children With Autism • The long-term prognosis for people with autism is poor • Early diagnosis clearly allows for more effective treatments (National Research Council, 2001) • A higher IQ may mean a better ability to generalize learning and therefore a better overall prognosis • Severe cases are less likely to improve with treatment A Case Study of Childhood Autism • John O’Neil, a deputy editor at the New York Times, described what it is like to be the parent of a child with autism (O’Neil, 2004) – Many children who will develop autism show abnormal social behavior in infancy – Most diagnoses of autism are made by age 3, but the disorder can be detected earlier if parents or pediatricians know what to look for – Signs include staring at objects for long periods, not reaching developmental milestones, withdrawal from social contact, stopping babbling, self-abuse – The earlier diagnosis and treatment begins, the better the prognosis • Luckily for O’Neil’s son James, preschool staff recommended a professional evaluation because of his unusual behavior and he received treatment “Autism and Virtual Pals” Kids with autism have trouble listening and responding, but they may get some help from a virtual friend. As this ScienCentral News video explains, technology could help isolated kids make connections in the real world.