Lessons 04 - 06 Flashcards
Biological therapies for SZ
Most common treatment for SZ is antipsychotic drugs
Can be taken as a syrup, tablets or injection
Nearly all patients are given drugs either for a short or long period of time. They may be given psychological therapies after
Typical antipsychotics
Dopamine antagonists that work by reducing the effects of dopamine, and therefore SZ symptoms (only positive ones e.g. hallucinations, delusions). They block the dopamine receptors, preventing dopamine from binding to the next neuron; it reduces levels of excitation.
Tablet, syrup or injection
Typical dosage is 400 - 800 mg
Maximum dosage is 1000 mg
Example: Chlorpromazine. Used to be used as a sedative.
Atypical antipsychotics
Used to minimise side effects. Also have a beneficial effect on negative symptoms. Work by blocking D2 receptors temporarily, and then rapidly dissociate to allow normal dopamine transmission.
Clozapine: used as syrup or tablet, as it has fatal side effects (blood condition). Works by binding to dopamine receptors, but also works on serotonin. By working on other neurotransmitters, it helps to reduce anxiety and depression.
Risperidone: syrup, tablet or injection. Better than clozapine (binds to receptors better) as it has less side effects
Evaluation of drug therapy
(+) Research evidence to support the moderate effectiveness of typical antipsychotics. Thornley (2003) compares the use of chlorpromazine with a placebo. Shows that typical antipsychotics were effective in reducing SZ symptoms than a placebo.
(+) Research to support the appropriateness of atypical antipsychotics. Clozapine was found to be effective in 30-50% of cases where typical antipsychotics failed.
(+) Research to show relapse rates are lower with drugs than placebos. Within 12 months, 64% of placebo patients relapsed compared to 27% of drug patients relapsed
(-) Serious side effects: dizziness, agitation, sleepiness, ‘tardive dyskinesia’ (involuntary facial movements), NMS (neuro malignant syndrome, could lead to death), blood condition (agranulocytosis) due to clozapine.
(-) Some drug trials have their data published on multiple occasions, so there is a problem with exaggerating the effectiveness. Also does not show how much the drugs reduce the symptoms. Also, most studies only assess the short term benefits.
(-) Ethical issues, e.g. consent. Someone with SZ may not be in the right state of mind to give fully informed consent.
Psychological therapies
Cognitive Behavioural Therapy (CBT)
Family Therapy
Token Economy
Cognitive Behavioural Therapy (CBT)
CBTp - p stands for psychosis
NICE (National Institute for Health and Care Excellence) recommend that all people should be offered CBTp. It helps people deal with symptoms and improves functioning. The aim is to help establish links between thoughts and feelings, and symptoms and general level of functioning.
a) Assessment: the patient expresses their thoughts, and realistic goals are set
b) Engagement: the therapist empathises with the patient and they understand that they need to work together
c) The ABC model: the patient explains the Activating events that caused the Behavioural Consequences. These beliefs can then be rationalised, disputed and changed
d) Normalisation: explaining that many people have unusual experiences, helping the patient to feel less alienated and stigmatised
e) Critical collaborative analysis: the therapist uses gentle questioning to understand the illogical thoughts (trust is needed to make sure it is done without causing distress)
f) Developing alternative explanations: the patient develops their own new ideas for their previously unhealthy assumptions. Positive self-talk is important
Done in groups or more likely to be one-on-one
NICE recommends 16 sessions
Patients are encouraged to trace back to the origins.
The therapist should let the patient develop their own alternatives
Evaluation of CBT
(+) More effective compared to standard care (antipsychotic drugs alone), according to NICE. CBTp was effective in reducing hospitalisation rates up to 18 months following the end of treatment. Also reduces the severity of symptoms
(+/-) The effectiveness is dependent on the stage of the disorder. Addington and Addington (2005) found that in the initial phase, self-reflection is not appropriate. However after stabilisation with medication, CBTp is beneficial. BUT it is hard to know when a specific treatment should be made available.
(-) Lack of availability, and refusal to attend sessions. Only 1/10 people have access to CBTp. Haddock et al. (2013) found that in North West England, 13/187 patients (7%) were offered CBTp. People also refuse or fail to attend, limiting its effectiveness even more
(-) Problems with meta analysis. Failure to take into account the quality of the studies. Can reach unreliable conclusions. For example, some studies fail to randomly allocate participants to each condition (control or CBTp). Wykes et al (2008) found that the more rigorous the study, the weaker the effect of CBTp.
Family therapy
The aim is to provide support for carers in an attempt to make the family life less stressful and reduce hospitalisation. Involves providing family members with information about SZ
Offered for a period of 3-12 months and at least 10 sessions. Commonly used with routine drug treatment.
Garety et al. (2008) estimates that the relapse rate for individuals who receive family therapy is 25% compared to 50% with standard care (drugs).
By reducing levels of expressed emotion and stress, it attempts to reduce relapse rates. There are a number of strategies used.
a) Psychoeducation - helping the person and their carers to understand and deal better
b) Forming an alliance with relatives
c) Reducing the emotional climate within the family
d) Enhancing relatives’ ability to anticipate and solve problems
e) Reducing expressions of anger
f) Maintaining reasonable expectations
g) Encouraging relatives to set appropriate limits
Key study for Family Therapy
Pharoah et al. (2010) reviewed 53 studies conducted in Europe, Asia and North America (+ population validity) to investigate the effectiveness of family intervention.
Compared to standard care (antipsychotic medication alone),
- Mental state: the overall impression was mixed - some studies showed an improvement in overall mental state, some did not
- Compliance with medication: increased with family therapy
- Social functioning: did not have much of an effect, but an improvement to general functioning
- Reduction in relapse and readmission: a reduction during treatment and in the 24 months after.
Evaluation of family therapy
(-) Is it effective? According to Pharoah’s study, it increased patience compliance with medication (suggesting it is effective), but does not improve social functioning (suggesting it is not effective). The evidence from the study is mixed.
(-) Lack of blinding in family therapy studies. 10/53 studies from Pharoah did not use any form of blinding, meaning the raters knew which participants were allocated for which conditions, which means there would be bias. A problem because it does not tell us if it is effective
(+) Economical benefits. NICE said that family therapy is associated with significant cost savings (reduction in costs of hospitalisation because of lower relapse rates). The costs saved are bigger than the costs of family therapy.
(+/-) Impact on family members. Lobban et al. (2013) found that 60% of the studies they looked at reported a significant positive impact in at least one outcome category for relatives (e.g. coping and problem-solving skills, family functioning, relationship quality). However, the methodological quality of many of the studies were poor, so it is difficult to distinguish effective from ineffective
Token Economy
Encourage good behaviour, ignore bad behaviour.
Based on the principles of operant conditioning.
Reward systems used for behavioural shaping and management in hospital settings. It is common for institutionalised patients to develop bad hygiene. Changing these bad habits does not cure SZ, but improves a patient’s quality of life, and makes it more likely that they could live outside a hospital setting.
Rewards for good behaviour = positive reinforcement
The tokens can be swapped for a tangible reward e.g. sweets. They are given immediately when patients have shown a desirable characteristic, so the patient can associate the good behaviour with the reward.
Tokens are secondary reinforcers because they only have value when a patient learns that they can be used to obtain rewards
Evaluation of token economy
(+/-) Research support. Dickerson et al. (2005) revised 13 studies, and found that 11 of them report beneficial effects from the use of token economies. However, many of the studies had methodological issues which could have affected the overall impact of token economies
(-) Ethical concerns. Clinicians may exercise control over important primary reinforcers, such as food or privacy. It is generally accepted that humans have certain basic rights that should not be violated.
(-) Lack ecological validity. Although token economies have been proven to be effective in reducing negative symptoms, it has only shown to work in hospital settings. In a hospital, people receive 24 hour care, and can be given tokens immediately after good behaviour. In the real world, it is much harder. Therefore they cannot be used in the real world
There is no conclusive evidence. It is fairly new.
Interactionist approach
AKA the biosocial approach
Acknowledges that there are biological (genetic vulnerability and neurochemicals), psychological (stress) and societal factors in the development of SZ.
Treatments acknowledge both biological and psychological factors, therefore the approach is associated with combining antipsychotic medication and psychological therapies (CBT).
In Britain, it is standard practice to treat patients with a combination of drugs and CBT
Diathesis stress model
States that both a genetic vulnerability and a stress-trigger are necessary in order to develop SZ.
Meehl’s original model was entirely genetic and said there was one ‘schizogene’. However, the modern understanding states that many genes increase genetic vulnerability, and also psychological trauma affects SZ.
Read et al. (2001) proposed that early trauma affects brain development. It can make the HPA system overactive, making a person more vulnerable to stress.
Cannabis use makes it 7x more likely for a person to develop SZ (interferes with the dopamine system). But this is not the only cause, so there are clearly other stressors
Evaluation of the interactionist approach
(+) Evidence for the role of vulnerability and triggers. Tienari et al. (2004) studied kids with SZ mothers, who were adopted by other people. Kids with SZ mothers were more likely to develop SZ than a control group. A child-rearing style with high levels of criticism and conflict, and low levels of empathy was implicated in the development of SZ. Strong support for both genetic vulnerability and family-related stress
(+) Support for the effectiveness of combination of treatments. Tarrier et al. (2004) found that patients who received both medication and CBT showed lower symptoms than those in a control group (medication only). Shows a clear advantage to adopting an interactionist approach
(-) Original diathesis-stress model is too simplistic. We now know that there are multiple genes (no schizogene), and that stress comes in many forms (dysfunctional parenting, childhood trauma, cannabis). Shows the old model is too simple.
(-) We don’t know how diathesis-stress model really works. We don’t understand the mechanisms by which symptoms appear and how vulnerability and stress produce them. Shows that there is an incomplete understanding
(-) Treatment-causation fallacy. Just because the combined treatment is more effective than just one treatment, does not mean the interactionist approach is necessary correct. The superior outcome of combined treatments should not be over-interpreted in terms of evidence in support for the interactionist approach.
