The different approaches propose different kinds of therapy.
The medical model proposes treatments that intervene in the biological system,
and the psychological approaches all proposes different therapies, which relate
to their basic assumptions.
The medical model
Somatic therapies are
derived from the medial model, which views mental disorder as an illness. Treatment
therefore revolves around a range of somatic approaches such as drugs, ECT and
psychosurgery.
Drug therapy
Communication between
neurons involves the release of neurotransmitter substances. Various drugs can
affect the production or release of one or more of neurotransmitters, and they
can also mimic the effects of transmitter substances on receptor molecules,
block these effects, or interfere with the reuptake of a transmitter substance
once it is released. Via these mechanisms, a drug can alter the perceptions,
thoughts, and behaviours controlled by particular neurotransmitters. Antipsychotic
drugs alleviate symptoms of schizophrenia by blocking dopamine receptor
molecules in the brain. Anti-anxiety drugs depress behaviour and cause relaxation
(sedation).
Drug therapy is also known
as chemotherapy. Drugs were first used to treat mental disorders in the
19th century. Since the 1950s their use has become widespread, and they account
for a large proportion of NHS prescriptions. In 1979, for example, 30.7 million
prescriptions for Benzodiazepines (one type of minor tranquilliser) were
dispensed according to Taylor (1987). The psychoactive drugs typically
operate by affecting transmission in the nervous system (neurotransmitters such
as dopamine, serotonin, noradrenaline, GABA etc.) and basically the outcome
is to increase or decrease the levels of available neurotransmitters. Depending
on which neurotransmitter they affect, and whether they enhance or diminish
its effectiveness, they can have calming or energising effects on different
kinds of behaviour. The different methods of action of different drugs also
mean that they have different side effects.
Three major groups of psychoactive drugs are used: Anti-depressants, Major tranquillisers and Anti-anxiety drugs
Anti-depressants drugs are used to elevate the mood of depressive patients, and to reduce panic in anxious patients. They may therefore be given for disorders as diverse as anxiety, agoraphobia, obsessive-compulsive disorder, panic attacks, eating disorders and Seasonal Affective Disorder (SAD). They can be divided into three major groups according to the way in which they achieve their effects; the outcome in all cases is enhancement of the action of one or more neurotransmitters.
One drawback with the use of antidepressants is that it may be several weeks before any beneficial effects are seen, and this is rather puzzling since the effects of such drugs on neurotransmitter levels are almost instantaneous. Side effects are also found varying with the type of antidepressant used. The MAO inhibitors and TCA are ‘dirty’ compounds, which affect a number of bodily systems. The MAO inhibitors are the least used, and most of them require dietary restrictions so that patients must avoid foods such as cheese, chocolate, yeast, bananas, yoghurt, alcohols and chicken livers, all of which contain the protein tyramine. If a diet is not observed, hypertension may follow and this may cause a brain haemorrhage. They also have dangerous interactions with other drugs such as cold remedies. Side effets include urinary retention, damage to the liver and cardiovascular system, cardiac arrhythmias, dry mouth and blurred vision. New versions of the drugs do not have these side effects (RIMAs, or reversible inhibitors of monoamine oxidase). Tricyclics have side effects such as dizziness, blurred vision, sweating, weight gain, constipation, poor concentration, impaired short-term memory, sleepiness and dry mouth. The newer SSRIs (e.g. Prozac) have fewer side effects, but they can still cause nausea, stomach upsets, insomnia, dizziness, headaches, nervousness and impaired sexual function. ‘Prozac’ is now the most widely prescribed anti-depressant medication (Costello et al. 1995). Lithium carbonate is used to treat bipolar mood disorder by stabilising neurones, preventing the development of mania but the precise mechanisms remain unclear so this drug also stabilises mania
General evaluation: antidepressant drugs are an effective way
to treat depression and anxiety in the short term, significantly helping 60
to 80 % of people according to some reports (Bernstein et al. 1994). However,
they are not equally effective in all cases and may not be better than psychotherapy
in the long term. A recent and controversial study by Kirsch and Sapirstein
(1998) analysed the results from 19 studies, covering 2.318 patients who had
been treated with the anti-depressant Prozac. They found that antidepressants
were only 25% more effective than placebos, and no more effective than other
kinds of drugs, such as tranquilisers.
ABSTRACTof the Kirsch and Sapirstein study (1998)
Mean effect sizes for changes in depression were calculated for 2,318 patients who had been randomly assigned to either antidepressant medication or placebo in 19 double-blind clinical trials. As a proportion of the drug response, the placebo response was constant across different types of medication (75%), and the correlation between placebo effect and drug effect was .90. These data indicate that virtually all of the variation in drug effect size was due to the placebo characteristics of the studies. The effect size for active medications that are not regarded to be antidepressants was as large as that for those classified as antidepressants, and in both cases, the inactive placebos produced improvement that was 75% of the effect of the active drug. These data raise the possibility that the apparent drug effect (25% of the drug response) is actually an active placebo effect. Examination of pre–post effect sizes among depressed individuals assigned to no-treatment or wait-list control groups suggest that approximately one quarter of the drug response is due to the administration of an active medication, one half is a placebo effect, and the remaining quarter is due to other nonspecific factors.
Major tranquillisers act to reduce the level
of dopamine in the brain by blocking certain types of receptors for dopamine
in the nervous system. Their beneficial effect include a general calming effect,
and the reduction of psychotic symptoms such as hallucinations, confusion, and
movement disorders. However, they have little effect on such negative symptoms
as withdrawal and listlessness, and have some side effects. A drug like chlorpromazine
is considered to have revolutionised psychiatry because the most disturbed patients
have been able to live outside the psychiatric ward. Some these drugs have been
called ‘chemical straitjackets’ because they produce a zombie-like
state. The way chlorpromazine works: it concentrates in the brainstem and is
released slowly which prolongs its effect on the brain. At first, striking sedation
effect which wears off gradually. A reduced responsiveness to external stimulation
and gross motor activity. Research has shown that it is superior to placebo
in controlling hallucinations, excitement, thought disorder and delusion and
it seems to have beneficial effects because it blocks the D2 receptor for dopamine.
Side effects: dry mouth, blurred vision, low blood pressure, neuromuscular effects
(like in Parkinson’s disease) like tardive dyskinesia in around 30% of
the patients (involuntary ticks and spasms and uncontrollable writhing of the
tongue. This should deter from long-term prescribing Gelder et al. (1989 because
it is more likely to be seen with prolonged use of the drug,). Another drug
is clozapine, which is more effective for some patients and not associated with
movement disorders to the same extent. However, a serious side effect may be
a fatal inhibition of white blood cell production (agranulocytosis) in a small
percentage of patients. The presence of such problems means that other drugs
may be needed to control the side effects, and that regular blood tests may
be necessary to monitor white blood cell counts. A recent version of this type
of ‘atypical antipsychotic’, called olanzapine, is thought not to
affect the white blood cell count in this way.
Evaluation: Although such drugs do not appear to help all sufferers, and long-term use may not be possible, it has been found that they can be more effective than other therapies (including the use of placebos, or even ‘dummy drugs’) for schizophrenia and they may help to prevent relapse.
Anti-anxiety drugs (or minor tranquillisers
, benzodiazepines or anxiolytics) (phenothiazines, antischizophrenic drugs or
neuroleptics: These anti-anxiety drugs are designed to treat every-day anxiety
disorder ( but not psychotic symptoms) from a wide range of phobias to generalised
anxiety disorders. A drug called Alprazolam, for example, has been found to
be helpful in the treatment of panic disorder and agoraphobia (Klosko et al.
1990). They may also be helpful with stress-related disorders and with reactive
depression, as well as helping people who are undergoing withdrawal from alcohol
and drug addiction.
These drugs operate by depressing activity in the CNS, which in turn reduces
activity in the Sympathetic Nervous System. This is responsible for the physiological
changes (such as increase in heart rate) which are associated with emotional
responses. The senseitivity of receptors to GABA is also increased, and because
GABA is an inhibitory transmitter, blocking responses, this leads to inhibition
of behaviour.
The side effects of these drugs can be considerable, especially with long-term
use. As well as lethargy, dependency on the drug develops, along with increased
tolerance and withdrawals symptoms such as tremors, convulsions and increased
anxiety if the drug is no longer used. The drugs are also toxic, so an overdose
can lead to deathe, especially if combined with alcohol. However, a more recent
drug in this group, buspirone, is slower acting but does not promote dependence,
interact with alcohol or cause cognitive or motor impairment. It affects serotonin
receptors rather than GABA receptors. Despite the apparent lack of side effects,
10% of patients still stop using it (Okocha 1998). Although use of these drugs
is now falling, many writers feel that they have been misused as a method of
social control (Gabe, 1996), especially in the treatment of women. When pressure
to comply with traditional gender roles produces symptoms of mental disorder,
it could be argued that the use of medication to alleviate symptoms condones
such social pressures.
Neprobamate (a mild barbiturate) have side effects but it was on the market
until the early 1960s where chlordiazepoxide (Librium on the market) and diazepam
(Valium on the market) quickly became the most prescribed drugs. In 1989, in
UK alone there were 21 million prescriptions (Rassool and Winnington, 1993).
Originally these drugs were called minor tranquillisers as opposed to major
tranquillisers used to treat psychotic disturbances but now they are just called
‘tranquillisers’. They work by facilitating the activity of GABA.
Growing evidence that the brain produces its own anti-anxiety compounds, which
are released during periods of stress.
Hamilton and Timmons (1995) believe that the combination of these drugs with
psychotherapy is the most productive way of treating severely disturbed patients.
Drugs alone cannot provide a cure.
Evaluation of drug therapy
In general, drugs have
been extremely effective in reducing the numbers of hospital in-patients who
are being treated for dysfunctional behaviour, but it is important to note that
such reductions in numbers also reflect changing policies towards hospitalisation.
Drugs provide effective long-term control for mood disorders and psychotic illnessess,
and may help to prevent suicide in depressive patients and to reduce anxiety
in neurotic patients.
The side effects observed
represent a major drawback, and raise important ethical issues. Unless treatment
is regarded as an emergency, it cannot be given without the patient’s consent
(except where the patient may not be capable of giving consent). This consent
should be given on the basis of full information about the potential benefits
and drawbacks of the drugs concerned, in which case it fulfils the ethical criterion
of informed consent. Apart from the side effects, the main criticism of drug
treatments is that although they are effective in reducing the symptoms of mental
disorder, they do not constitute a cure and have therefore been seen by some
as merely a chemical straitjackets.
ECT or electroconvulsive therapy
Historical background: Attempts to alleviate psychoses by inducing
comas or epileptic-type seizures date back to Sakel in 1938, who used insulin
injections to produce comas. In the same decade, von Meduna observed (incorrectly!)
that schizophrenia and epilepsy did not occur together in the same patient,
and thought that inducing an epileptic seizure would therefore eliminate schizophrenia.
He used various drugs to induce convulsions, but it was Cerletti and Bini who
in 1938 initiated the use of an electric shock across the temples to do this.
The procedure is now used to treat severe depressive patients but there is only
inconclusive evidence why it works. When first introduced, it caused such severe
muscle spasms that broken bones were reported, and the treatment was also associated
with cell death in the cerebral cortex of the brain. Side effects reported included
memory loss, speech disorders and even cardiac arrest (Liskey & Gordon 1991).
Modern procedures involve reduced shock levels and muscle relaxants, as well
as the administration of a general anaesthetic so that patients find the experience
less frightening. As this is not classed as an emergency treatment, informed
consent must be obtained. Electrical current is applied via electrodes (both
bilateral ECT and unilateral ECT (applied to the non-dominant hemisphere side,
often the right) and this is aimed at reducing side effects like memory disruption
(Benton, 1981), but since memory is already affected in depression, it is difficult
to say if the impaired memory function is due to the treatment. Current of 110
mv (200 ma) is passed for between half a second to five seconds, causing only
slight facial twitches to appear. Consciousness is regained after about five
to twenty minutes. Usually a series of four to six such treatments will be given
over a period of several weeks.
Now there is a low mortality rate (equals death because of anaesthesia) and
ECT is one of the most widely used and according to many clinicians, it is one
of the safest and most efficient medical treatments in that 60 to 70 % of patients
(if you calculate that many depressive will commit suicide). Consequently it
is the preferred treatment for severe depression during pregnancy. Breggin (1979)
demonstrated that brain damage could occur following administration to animals.
Another criticism is based on a survey of 308 patients, which showed that 2/3
of them did not regard the treatment as helpful, and half of those also felt
that it had in fact been damaging (UKAN 1995).
The main objections to the treatment are, however, ethical: we don’t know
how it works (or if it works) so it should not be used, and another issue is
‘consent’. Despite these objections, ECT seems to be currently enjoying
a revival. (Twombly, 1994).
Evaluation
of ECT:
Psychosurgery
Psychosurgery is the use
of brain surgery to destroy a small area or to isolate an area by cutting its
connections with the rest of the brain. If the area concerned is malfunctioning,
this procedure should alleviate the psychological problems that the area is
causing. Prefrontal lobotomy is now extremely controversial now but it
was widely used at a certain time. Moniz discovered the tranquillising
effects of lesions to the frontal lobes of monkeys, and he performed the first
pre-frontal lobotomies (or leucotomies) on human schizophrenics in 1935. From
1935 to 1946, he performed about 100 operations on human schizophrenics. He
won the Nobel prize in 1949 and was later shot by one of his patients, so that
he had to stay in a wheel chair for the rest of his life.
Freeman and Watts
(1942) introduced psychosurgery in the USA, and it has been estimated that 40.000-50.000
pre-frontal lobotomies have been performed (transborbital lobotomy). They developed
Moniz’ technique (see figure 31.2) and in spite of unacceptable side effects
it was widely used both in the USA and in UK (about 10.000 operations from 1942-52)
both on depressives and schizophrenics. Since the 1950s and the introduction
of drug treatment, these approaches have become much less popular, often being
used only as the last resort. Snaith (1994) has estimated that only about 20
operations per year are carried out in the UK at present, although other estimates
give figures up to 50. The main uses are to treat severe anxiety and depression,
or obsessive-compulsive disorder.
Refined surgical techniques
mean that very precise damage can now be caused to clearly-defined areas. Lobotomies
now involve drilling two small holes in the forehead through which radioactive
rods can be inserted: electrical probes or lasers can also be used to burn out
tissue in selected areas. For example, a bilateral stereotactic subcaudate tractotomy
cuts the pathway between the limbic system and the hypothalamus and is used
to treat depression. Obsessive-compulsive disorder is treated by a cingulotomy,
which cuts the connections between the prefrontal cortex and the limbic system.
Aggressive and violent patients can be treated with a limbic leucotomy.
Modern psychosurgery techniques
appear to cause less intellectual and emotional impairment than some of the
earlier techniques, which had serious side effects such as major personality
change and even death. Baer et al. (1995) reported a long-term follow-up study
of 18 people who had cingulotomies for OCD because they had not responded to
psychotherapy. They showed improved functioning, were less depressed and anxious
and had few negative side effects. However, psychosurgery is not always successful,
nor is it always clear why it works when it does, or exactly what the effects
will be in any one case. Since operations are irreversible, side effects are
also permanent.
Side effects: apathy,
lethargy, epilepsy, intellectual impairment, aggressiveness and personality
changes, and death.
Abuse? Balasubramanian
(1970) used it on hyperactive children and reported a calming effect (a success!?)
and other examples (Taylor, 1972) operated a depressed woman who could have
been helped by drugs. Lobotomy was widely used before but now the figure has
dropped substantially, because the seriousness of side effects and no real follow-up
studies of patients who have undergone the procedure in order to control. (Gelder
et al. 1989).
Continue on to psychodynamic and learning theory therapies
Continue on to cognitive and humanistic therapies