copyright 2008 Cheryl K. Hosken, BSN, MS Psych.
Historical Perspective
The history of treating psychological disorders is not a pleasant one. There is not a history of active, humane intervention to improve persons who had psychological distress. People suffered much from treatment.
The ancient Greeks and Romans thought that persons who were depressed, manic, irrational, or intellectually retarded had offended the gods. Prayer and ritual were followed to improve their condition. More severely disturbed patients were seen as impossible to heal. The goal of treatment was to exorcise the evil spirits. As a result of treatment, many of these people died or were killed if the treatment failed.
Hippocrates believed that mental disorders had physical causes and not spiritual ones. He saw that epilepsy is a disorder of the brain. Some of his views were wrong, but he at least tried to demystify psychological disorders.
During the Middle Ages (1000-1500), the oppression of mentally ill patients was higher than at any other time. The prevailing opinion was that psychologically ill persons were "bad people" under the spells of devils and evil spirits. They were the cause of their own grief and there was no hope for them.
The first insane asylum was opened in London in 1547. It was a place where relatives left mentally ill people, and various treatments were tried from the letting of blood to starving. There was no professional staff. Until well into the 18th century, the attitude to mentally ill persons was that God was punishing them for sinful thoughts and deeds. If persons did not confess to being sinful, they were tortured. If the torture did not help, death was the cure.
The beginning of humane treatment of mentally ill in the West was in France in 1793. The physician, Phillippe Pinel, had compassion on the people in his hospital who were chained to the walls. He ordered the chains be removed from his patients. As a result of his actions, the patients moved around freely and many of their symptoms improved. Dorthea Dix in the U.S. was a leader in changing laws for care of the mentally ill during the 1840s. The main stimulus for promoting legislation of the mentally ill in the States was a book written in 1908 by Clifford Beers. He suffered from bipolar mood disorder. He recovered despite attitudes and treatment at the time.
Biomedical Treatment of Psychological Disorders
We will review three types of biomedical intervention: psychosurgery, electro-convulsive therapy, and drug therapy. The most promising of these three is drug therapy.
Psychosurgery is a surgical procedure done to the brain to effect psychological reactions. In extreme cases of epilepsy, if the corpus collosum is destroyed, the seizures are relieved. Violent behavior is stopped by making small cuts in the limbic system.
Probably the most common type of surgery is the frontal lobotomy. This surgery severs the major neural connections between the front part of the brain and the lower brain centers. It was originally thought that severely disturbed patients had difficulty controlling the lower part of the brain by use of the cerebral cortex. The reasoning was that if these areas of the brain were separated, the violent behavior would be controlled.
Meditate Word By Word On These Verses:
Acts 19:13-20.
Tens of thousands of these surgeries were done in the 1940s and 1950s. This was an irreversible procedure and with research on the effects of the surgery, the results showed terrible side effects. About 4% of the patients died. Many who survived had seizures, memory loss, inability to plan, and loss of affect. Many were difficult to manage because they had childish behavior following the surgery. These surgeries are not done today because there is no need for them.
Question:
1. Why is psychosurgery rarely performed today?
(Only one of the following answers is correct.)
Because the evil spirits move to the remaining parts of the brain.
Because it is difficult to reverse the procedure.
Because with new therapies there is no need for psychosurgery.
Electro-convulsive therapy was introduced into psychotherapy in 1937. It involves sending an electric current through the brain for a fraction of a second. Patients are under anesthesia when the shock of electricity is given them. They also receive a muscle relaxant to decrease the muscular contractions that follow the shock. The procedure takes 5 minutes and resembles a seizure of epilepsy.
The procedure was first used for calming agitated schizophrenics, but it soon became clear that those with major depression were helped the most. The most common side effects are loss of memory and a general mental confusion. These symptoms disappear in a few days or weeks. The benefits of the electrotherapy may last for months.
No one knows why the electrotherapy works. It is still very much in use. Again, the use of drugs has reduced the need for electro-convulsive therapy. This therapy is now saved for patients with whom:
- drugs are ineffective,
- patients with acute suicidal tendencies, and
- depressed patients who suffer from delusions.
Question:
2. What is electrotherapy and why is it still used?
Drug Therapy
Psychoactive drugs are those that alter a person's affect, behavior, or thinking patterns. The use of chemicals to improve the condition of the mentally disordered is one of the most important achievements of this century. There are three main types of drug therapy: the anti-psychotic drugs, antidepressant drugs, and anti-anxiety drugs.
Anti-psychotic drugs alleviate or eliminate psychotic symptoms. Psychotic symptoms show a loss of contact with reality. These symptoms are delusions, hallucinations, loss of emotional affect, and impairment of daily functioning. These drugs are used to treat schizophrenia, but may also be used to treat substance abuse disorders.
In the 1950s, a French doctor used a drug for his preoperative patients to calm them before surgery. The drug is called chloropromazine or Valium. The effect on his patients was good. Therefore, he thought the drug might also be used for schizophrenic patients. The controlled experiments with this drug were good and soon psychologists were using it for their patients to help them with their symptoms. With the success of this drug, the search for other chemicals that could improve the symptoms of the mentally ill began.
The anti-psychotic drugs all work in the same way. They block the receptor sites for dopamine. Anti-psychotic drugs are most successful in treating the positive symptoms of schizophrenia: delusions, hallucinations, and bizarre behaviors. The results of the anti-psychotic drugs have revolutionized the care of psychotic patients, however, about 30% of schizophrenic patients do not respond to these medications. These drugs are most effective when the illness is first diagnosed. Side effects from these drugs are dry mouth, sedation, sexual impotence, and some joint soreness.
Although these drugs suppress the symptoms, the question remains: Are they in any sense curing the disorder? In the usual sense of the word cure, they are not. Symptom-free patients who are released from care often stop taking their medications only to find that their symptoms return. If the patient decides to stop taking the drugs, it is better to slowly taper off their use.
Antidepressant Drugs
Antidepressant drugs elevate the mood of persons whoa re depressed. Some antidepressant medications may be useful in treating panic attacks and generalized anxiety disorder as well. An antidepressant drug can have three effects on a person - unpleasant side effects, no visible effect, or beneficial effect. These drugs do not elevate the mood of someone who is not depressed, that is, they do not give normal persons a euphoria.
There are three classes of drugs: MAO (monamine oxidase) inhibitors, trycyclics, and a newer class of antidepressants that act on neurotransmitter receptor sites (serotin and norepinephrine). Some of these drugs inhibit the re-uptake of serotonin.
The MAO inhibitors are the oldest class of antidepressants. These drugs are Parnate, Nardil, and Marplan. They inhibit the enzyme monoamine oxidase. This enzyme breaks down serotonin, norepinephrine, and dopamine in the brain. The result of the drugs is that there are more of the neurotransmitters in the brain and they elevate the mood of the person. However, these drugs are difficult to use and may be toxic. The tricyclics (Impramamine, Desipramine, and Trimipamine) are safer and more effective than the MAO inhibitor drugs. Tricyclics affect the way serotonin acts in the brain.
The drugs that block the destruction of serotonin in the brain are no more effective than the tricyclics, but they act faster than the tricyclics to relieve symptoms and have fewer side effects. Prozac was introduced in 1987. It is now the most prescribed drug for depression. It works by stopping the breakdown of serotonin in the brain and thus causes higher levels of serotonin that elevates mood. The names of three other drugs in this class are Zoloft, Paxil, and Luvox. There are a number of other antidepressant drugs that work in the same way as Prozac, but I will not name them here since they have different names in different countries.
Question:
3. What are the three major types of psychoactive drugs?
Why are there so many drugs that appear to do the same thing? Although the final effect of the drugs is the same, each produces its effect differently. Different individuals respond in different ways to various antidepressant medications. What works well for one person might cause problems for another. The final conclusion is that the exact manner in which they work is not known. Having many choices makes it more likely that a physician or psychiatrist can find the medication that will be best for the patient.
We also need to remember that these drugs take about 10-14 days to show any effect. Their full effect may take six weeks, and they need to be taken long-term to prevent recurrence of depression. The side effects can be intellectual confusion, increased perspiration, and weight gain. Some of these drugs require a strict diet and frequent monitoring of blood levels of the drug.
Another drug that is often used is lithium salts. They are mood stabilizers. They help depression, but are most useful in controlling the manic stage of bipolar disorder. The lithium is effective in preventing or reducing future episodes of the disorder. A newer drug, Depakote, seems to be effective as lithium, has fewer side effects, and acts faster.
The antidepressant medications can actually bring about long-term cures rather than symptom suppression. The drug may actually change the mood of the person enough so that the dosage may be reduced over time. In fact, the goal of such medical treatment is to reduce the drugs to minimum levels or gradually take away the drug from the patient.
Question:
4. What are the advantages and disadvantages of using psychoactive drugs?
(One or more of the following answers may be correct.)
They can cause intellectual confusion, increased perspiration, and weight gain.
They can actually bring about long-term cures rather than symptom suppression.
They cause delusions, hallucinations and loss of emotional affect
Tricyclics affect the way serotonin acts in the brain.
Anti-anxiety Drugs
The anti-anxiety drugs reduce the feeling of anxiety. Some of the anti-anxiety drugs are muscle relaxants. They are Miltown and Equanil. When muscular tension is released, the patients feel calm and at ease. The other group of drugs includes the benzodiazepines (Valium, Librium, and Xanax). These are the most commonly prescribed of all drugs. They act directly on the nervous system to give calmness. The initial negative side effects are slight drowsiness, blurred vision, and slight impairment of coordination.
Question:
5. What is a problem that these drugs cannot fix?
Unfortunately, these drugs are not long-acting and the tranquilizing effect wears off. Patients can begin to use of pattern of relying on these drugs to alleviate the slightest fears and worries. Addiction can also develop. As long as one can ease anxiety with a little pill, there is little motivation to seek the cause of one's anxiety. Therefore, it is important that the dosage and length of time on medication be monitored closely.
Question:
6. Which of these drugs are addictive?
(Only one of the following answers is correct.)
MAO inhibitors.
Drugs that block the destruction of serotonin
Anti-anxiety drugs.
Psychotherapy
The major goal of various psychotherapy techniques is to help a person to think, feel, or act more effectively. Different types of therapy have different goals. We will talk about 5 types of therapy and the ways in which professionals may interact with a client. It has been said that if one has a good friend, one does not need a psychotherapist. What do you think about that opinion?
Question:
7. How did David feel because of his sin (Ps. 51:1-14) after the prophet Nathan exposed David?
Psychoanalytic Techniques
Psychoanalysis is based on several assumptions about conflict and the unconscious mind. Of course, in the West, Sigmund Freud is the most well known. He thought that one's life is often a struggle to resolve conflicts between opposing forces. For example, the biological, sexual and aggressive strivings of the id are in conflict with the superego, which is overly cautious and produces guilt. The strivings of the id can also be in conflict with the ego, which is rational and reality-based. The ego mediates between the id and superego. Anxiety-producing conflicts that go unresolved are repressed or forced out of awareness to the unconscious mind. These conflicts are produced in childhood and cause symptoms later on in life.
Question:
8. Did Freud seem to think that sin could be a cause of psychological problems? Do you think this problem of sin should be addressed before therapy of any sort begins with a patient?
According to Freud, the way to rid oneself of anxiety is to enter the unconscious, identify what has been repressed, talk about it and then resolve it as well as possible. The problem-solving process includes insight and resolution. This process is very slow and time-consuming because the repressed conflicts are well-integrated into one's life situation.
Freudian Psychoanalysis
Freud believed that having patients talk about anything and everything get to the underlying conflicts that were causing the patient's symptoms. His method became the talking cure. The therapy required 5 days per week and up to 10 years of self-examination. The main task was to talk openly and honestly about all aspects of life from early childhood to the present. The main task of the therapist was to look for clues of repressed conflict.
Free Association - Patients were to say aloud whatever came to mind. Sometimes the analyst would say a word to provide a stimulus to get a chain of free-flowing associations started. The patients were to be completely honest and say whatever they thought. This was hard for persons of that time to do and therefore, Freud had the patients lie down to relax. Also, he did not make eye contact with them so that they were able to speak freely.
Resistance - During therapy, the analyst listens carefully to what the patient says and DOES NOT say. Resistance, or the inability to discuss one aspect of life is a significant process in analysis. Resistance can show itself in many ways: avoiding some topic, disruption of a discussion when a particular topic comes into discussion, or missing appointments with the analyst.
For example, a patient has seen an analyst for the last six months and talked freely about a number of subjects, including childhood memories, funny and sad events, but after this period of time, she has not said anything about her older brother. The analyst, noting this possible resistance, suggests that the next meeting, they discuss her relationship with her older brother. Then, for the first time the patient misses her next appointment. She comes to the following appointment, but she is late. Now the analyst suspects that there is a problem that may have begun in childhood that has been repressed for a long time. Of course, there may not be any problem at all, but to make the analysis successful, this topic will have to be investigated with the patient.
Dream Interpretation - Freud believed that dreams were the road to the unconscious level of the mind. He wanted his patients to recall and record their dreams in detail. The idea was that true feelings, motives, and desires might be camouflaged in a dream. For example, someone who reports a dream about driving through an endless tunnel might be expressing fears of might be in a situation where he feels there is no way for him to turn. The analyst was to interpret the dreams using the insight and information he got from the patient. Then the analyst might be able to help the person understand what had happened to his mind and thought patterns.
Transference - Transference occurs when the patient unconsciously begins to feel about his analyst the way he feels about another important person in his life, usually a parent. If feelings once directed to a parent are directed to the analyst, Freud argued that these feelings are more easily understood and worked on with the patient. The analyst has to guard against his own feelings toward the patient so that the interactions between patient and analyst are objective and not simply to emotional reactions.
Question:
9. What were the various techniques that Freud used in therapy? Did these techniques give us insight into treatment of psychological problems, and are some of them still used today?
Early in this century Freudian analysis was the only form of psychotherapy. Since the 1950s it became much less common. Probably the most significant change since Freud's practice is a concern for shortening the length of analysis. Now we talk about time-limited therapy. Today's therapists use interviews and discussions for helping patients. They do not insist to learn what happened in early childhood, but they tend to spend more time on the present. The thrust of therapy is to deal with the here and now, working on the patient's current anger and depression.
Question:
10. Do you think Freud's methods were helpful in general? Why or why not?
yes /
no.
Question:
11. What kind of professional in your country may use psychotherapy to treat patients?