Neuroscience and Clinical Semester 1 Week 10: Treating Psychopathology Flashcards
What are the different approaches to treatment?
Psychodynamic/psychoanalytic
Behaviour therapy
Cognitive behavioural therapy
Humanistic therapies
Family and systemic therapies
Pharmacotherapy (drug treatments)
Approach 1: Psychodynamic/psychoanalytic
Assumptions:
- Unconscious conflicts originate from early life experience, evoke ‘defense mechanisms’ (e.g. repression, denial, displacement), causing observable symptoms.
Aim:
- Identify unconscious conflicts, bring them onto conscious awareness (increasing insight), then develop strategies to resolve conflicts.
Techniques:
- Psychodynamic therapy - psychoanalysis e.g. free association, dream analysis
- Highly variable structure
Approach 2: Behaviour therapy
Assumptions:
- Disorders arise from faulty learning, both classical and operant conditioning
Aim:
- Use associative learning principles, particularly extinction, to ‘unlearn’/’relearn’ associations
Techniques:
- Classical conditioning: Exposure therapy (systematic desensitisation/flooding), aversion therapy
- Operant conditioning: Contingency management (financial rewards), response shaping (reinforce behaviours)
Approach 3: Cognitive behavioural therapy
Assumptions:
- Disorders caused by distorted ways of thinking and cognitive biases
- E.g. Cognitive distortion/bias = belief that people find you boring → consequence = social withdrawal → disorder = depression
Aim:
- Change the dysfunctional cognitions that underlie disorders
Techniques:
- Challenge dysfunctional beliefs and replace them with more rational beliefs, then test them out during ‘homework’
Approach 4: Humanistic therapies
Assumptions:
- Holistic, considers patient as a whole rather than specific cognitions/behaviours etc.
Aim:
- Encourage client to find their own solutions to enable them to move from one state (usually negative) to another
Techniques:
- Client-centred therapy
- Unconditional positive regard (non-judgemental) and non-directive (active listening, providing advice when asked)
Approach 5: Family and systemic therapies
Assumptions:
Many disorders arise from dysfunctional relationships with and communication between close family members
Aims + techniques:
Therapist leads discussion with the patient and family members. The therapist’s theoretical orientation is important.
Approach 6: Pharmacotherapy (drug treatments)
Assumptions:
- Disorders are caused by brain dysfunction that can be corrected, or at least temporarily alleviated, by medication
Techniques:
- Medication
- E.g. Benzodiazepines (anxiety), SSRIs (depression and anxiety), antipsychotics (schizophrenia)
Limitations of drug treatments:
- Side effects
- Overprescription medicalises everyday ‘problems of living’
- Many drugs are ineffective for people with mild symptoms
Goals of treatment:
- Provide relief from distress.
- Increase self-awareness and insight into problems.
- Teach coping skills to manage symptoms / distress.
- Identify and resolve the ‘root causes’ of the disorder.
- Depends on the type of treatment
How is treatment delivered?
- One-to-one
- Group therapy
- Computerised (C-CBT)
- E-therapy (E-CBT)
- Mobile apps (‘mhealth’, ‘mtherapy’)
- Telephone / videoconferencing
Why is it difficult to evaluate the effectiveness of treatment?
What counts as success?
- Complete remission vs improvement
- Change in emotion/cognition/behaviour
- Self reported vs objective improvement
Internal validity
- A therapy should be effective due to its core assumptions not due to a kind therapist etc.
Evaluating treatment: Case studies/series
Case study = detailed report of treatment provided to an individual patient and their outcome
Case series = descriptive report of treatment and patient outcomes in groups of patients who have received different types of treatments
- Both vulnerable to bias e.g. selection bias
Evaluating treatment: Sick people tend to get better
It’s not sufficient to give people a treatment, see if they improve, then make conclusions.
- Spontaneous remission = about 30% of people with anxiety or depression will get better with no formal treatment. - ‘regression to the mean’
- Placebo effects = role of expectations
- Structured social support = often, therapies offer attention, understanding and care which may be an effective treatment in itself
Evaluating treatment: control/comparison conditions
Waitlist control - putting people on a waitlist
- Spontaneous remission ✔
- placebo effects X
- structured social support X
- Ethical issues involved in withholding treatment
Befriending - provide social support
- Spontaneous remission ✔
- structured social support ✔
- placebo effects X
Active control - appears to be intended therapy but missing active ingredient e.g. placebo pill
- Spontaneous remission ✔
- structured social support ✔
- placebo effects ✔
- Difficult to do well e.g. talking therapy
Evaluating treatment: Comparisons to other treatments
E.g. CBT vs antidepressant
Include active control and waitlist control groups to determine:
1) If both treatments are better than doing nothing at all (waitlist).
2) If both treatments offer something over and above a placebo effect / structured social support.
3) If one treatment is superior to the other.
Evaluating treatment: Randomised controlled trial
Randomised to treatment group or control group
- Overcomes selection bias
Problems with RCTs:
- Expensive and high dropout rates, particularly for control group
- Doesn’t take into account patients’ preferred therapy (randomised patient preference trials)
- Focuses on statistical rather than clinical significance (which is better statistically rather than which actually improves people’s lives)
- May not generalise to typical settings or populations (strict inclusion criteria)
Biases:
- publication bias (more likely to get published if the results support the treatment)
- investigator/researcher allegiance bias (who funds the study?)
- commercial bias
Evaluating treatment: combine evidence across studies
- Narrative summaries: prone to bias
- Meta-analysis: enables synthesis of findings from many different RCTs
- Meta-meta analysis and ‘umbrella reviews’: meta-analysis of meta-analyses
Is there a treatment that works better?
- In RCTs, most therapies are more effective than control conditions
- However, they tend to find few differences between different types of treatment
Why are there few differences in effectiveness between different types of therapies?
Common factors: elements shared across different treatments that contribute to their effectiveness, e.g.
- Therapeutic alliance: the relationship between therapist and client.
- Empathy and active listening
- Hope and expectation
- Goal-setting and collaboration
- Psychoeducation
- Feedback and monitoring
- Emotional expression and catharsis
