3. Treatments of Schizophrenia What treatments of schizophrenia did you find? The treatments of schizophrenia that we will be looking at can broadly be defined as either psychological or physiological (biological). You need to know about two types of treatment. In the book, three therapies are listed. We are going to focus on ECT and CBT for both schizophrenia and depression. You might want to read about drug therapy when revising. For each therapy, you need to be able to describe what happens in the therapy, including the how the therapy works, any potential side effects, ethical issues raised and its effectiveness. Physiological treatments: Electroconvulsive Therapy (ECT) If we accept that, at least in part, schizophrenia is a physiological disorder, then it makes sense to treat it as a physical illness. Some treatments therefore focus on using physical methods to eradicate the symptoms of schizophrenia. ECT works by using electricity to induce an epileptic-like seizure in the patient. Why did this treatment come about? (pg234) _________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ____________ Do you think that this was a logical conclusion to draw? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ __________________ ECT was first developed by Cerletti and Bini in 1938, under the belief that by inducing a seizure in a schizophrenic patient, they should be able to reduce or eliminate the symptoms of schizophrenia. It then started to be used widely in the USA from the early 1940s. 1
Transcript
3. Treatments of Schizophrenia
What treatments of schizophrenia did you find?
The treatments of schizophrenia that we will be looking at can broadly be defined as either psychological or physiological (biological). You need to know about two types of treatment.
In the book, three therapies are listed. We are going to focus on ECT and CBT for both schizophrenia and depression. You might want to read about drug therapy when revising.
For each therapy, you need to be able to describe what happens in the therapy, including the how the therapy works, any potential side effects, ethical issues raised and its effectiveness.
If we accept that, at least in part, schizophrenia is a physiological disorder, then it makes sense to treat it as a physical illness. Some treatments therefore focus on using physical methods to eradicate the symptoms of schizophrenia.
ECT works by using electricity to induce an epileptic-like seizure in the patient. Why did this treatment come about? (pg234) _________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
Do you think that this was a logical conclusion to draw? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ECT was first developed by Cerletti and Bini in 1938, under the belief that by inducing a seizure in a schizophrenic patient, they should be able to reduce or eliminate the symptoms of schizophrenia. It then started to be used widely in the USA from the early 1940s.
A description of the modern process of ECT is on page 234 .
Watch the video clip from “One Flew over the Cuckoo’s Nest”. What are your initial feelings on ECT? What is different in this clip from the description on pg 234?
It has been argued that early application of ECT was used as a method of control and to subdue troublesome patients (if you get chance to watch the rest of One flew Over the Cuckoo’s Nest, this is what happens to the main character).
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Side Effects of ECT As with any medical procedure, there are risks involved. As the patient is given a general anaesthetic,
this carries its own risk. The mortality rate for ECT is quite low (about 5 per 100,000), a level comparable with deaths from anaesthesia alone.
Also, physical harm could come from the effects of an epileptic seizure. There have been reported cases in the past where patients have suffered broken bones and bruising due to the restraints used.
o However ___________________________________________________________________ ______________________________________________________________________________________________________________________________________________________
Bennet (2003) researched patient’s experiences of ECT, and many described it as a terrifying experience, and regard it as an abusive invasion of personal autonomy (being able to have control over your own body and behaviour). Some experience it as a damaging repeat of early traumas (such as physical/sexual abuse) and it undermined their trust in mental health professionals.
There can also be disruption to memory, including both retrograde amnesia, and difficulties in forming new memories. The patient if often very confused and disorientated for 40 minutes or so after the treatment, which could be distressing. However, recall of events prior to treatment gradually returns over the following week, although some degree of memory loss may persist for many weeks.
The Royal College of Psychiatrists (1997) claimed that ECT does not have any long term effects on memory or intelligence. Critics however have claimed that ECT does not only cause memory loss, but general mental and emotional dysfunction.
How does ECT work?One of the major problems with ECT is that there is not clear answer to how it actually works. Benton (1981) however identified three possible explanations:
Patients come to see ECT as a punishment for their behaviour. o What does operant conditioning state about the effect of punishment?
What should happen to the behaviour? __________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
o However, it has been found that when patients are given a “sub-convulsive” shock (where the patient still feels pain from the electricity, but it is not a high enough voltage to induce a seizure) they receive no benefit from ECT. What does this suggests about punishment?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The memory loss caused allows the restructuring of the patient’s view of life.o However, a different type of ECT called unilateral ECT (where only
one hemisphere is affected) causes less memory loss, and yet is also effective.
The shock produces a range of biochemical changes in the brain. Lilienfield (1995) proposed that the neurotransmitters noradrenalin and endorphins particularly are stimulated.
o However, for some people, the effects of ECT are permanent, which cannot be explained by the change in neurotransmitters levels, which would be temporary.
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Abrams (1997): Modern ECT researchers do not have any more of a clue to the relationship between brain biological events and treatment response in ECT than they did when ECT was first created.
Breggin (1997) proposes that ECT works by causing brain damage. Patients suffer anosognosia, a condition in which they deny their psychological and physical difficulties (rather like treating a mental illness by being permanently drunk). This state may be mistaken by staff and patents as improvement.
Effectiveness and Evaluation of ECT
When we want to see how effective a drug treatment is, what do we do? ___________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________Can we do the same with ECT? ____________________________________________________________ ______________________________________________________________________________________
Information from pg 235What did the American Psychological Association (APA) find? __________________________________ ____________________________________________________________________________________________________________________________________________________________________________However What did Tharyan and Adams (2005) find out about the effectiveness of ECT? ______________ ______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________Likewise Sarita et al (1998) found __________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
One issue with the use of ECT is that it is ignoring the role of psychological factors in schizophrenia. By only treating the symptoms, we may be ignoring important psychological factors involved in the development and or maintenance of the illness.
A further issue, linked to that above, is that ECT also ignores the role of the social and family situation of the patient.
Another weakness is that the evidence regarding the effectiveness of ECT is mixed. It is not clear exactly how effective it is, and exactly why either.
However, it seems that when ECT is combined with medication, it has a greater effect.
Ethical Issues
Since we don’t know how ECT works (and whether it does work at all), should it be used as a treatment for schizophrenia? _________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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What advantage does ECT have over other forms of therapy, for example psychosurgery?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
As mentioned previously, ECT has been accused of being used as a method of control, and there is evidence that this is how it was used in psychiatric hospitals.
o However, its use for schizophrenia has reduced over the last few decades. ECT is mainly now used as a treatment for depression, where the patient has to give consent for the procedure. If the patient cannot give consent, consent has to be gained by a close relative.
o What has the decline in the use of the procedure been in the UK between 1979 and 1999? ___________________________________________________
Another major ethical issue is that if we are not sure how something works, we can also not be certain of any long term damage that it may be caused through the use of the therapy. Such damage may be irreversible, and may have long term negative consequences for the person.
The aim of CBT is to challenge maladaptive thoughts and replace them with constructive thinking that will lead to healthy behaviour. Schizophrenic people are often unaware that they are subject to cognitive errors, or that there are problems with their thinking. The therapist will try to make these maladaptive thoughts conscious, and then by challenging them, the patient will see that there is no basis for these thoughts.
CBT draws from both the cognitive and behavioural fields of psychology. The cognitive aspects include altering the way that the patient thinks about the world, and the behavioural side comes about by altering the patient’s behaviour through learning.
A description of the some CBT methods is on page 234 .
How effective is CBT for schizophrenia?
What did Drury (1996) find? _______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
One of the major issues with determining how effective BT is for schizophrenia comes from the fact that most of the time, CBT is conducted alongside anti-psychotic drugs. Kulpers (1997) noted this issue, but commented that generally, CBT seems to be effective.
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However, CBT may not be for everyone. What did Kingdon and Kirschen (2006) find? ________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CBT for patients who hear voices
A pure cognitive approach would explain schizophrenia as being the result of faulty information processing, such as in language, attention, thought and perception. Frith (1992) argues that schizophrenics fail to
monitor their own thoughts, misattributing them to the outside world. When a person hears voices, it is actually their own inner speech being misinterpreted. Therefore, part of CBT will be getting the patient to recognise these voices as being part of their own mind.
Some practitioners believe that schizophrenics who hear voices can be helped to bring the voices under control using cognitive behavioural techniques. The process begins by asking the patient to focus on the nature of the voices that they hear – for example thinking about their tone, or whether they are male or female. They might also find external ways of focusing, by drawing pictures of the different voices. The therapist therefore helps the patient to recognise that the voices represent part of who they are.
Patients are also taught strategies to protect them against the wishes of the voices. For example, relaxation techniques, talking to others or only choosing to pay attention to the voices at particular times of day. Bentall et al (1994) argues however that the emphasis is on controlling the thought processes rather than understanding the unconscious thoughts and feeling behind them.Why could this be a limiting factor of this aspect of CBT? _________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
Can focussing on, rather than ignoring the voices be damaging? ___________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Romme and Escher (2000) however claim that focussing on the voices actually reduces the likelihood of harm to the self or others.
Evaluation of CBT
Like ECT, CBT also ignores the role of family and society in both the cause and the maintenance of schizophrenia.
What is the biggest problem with only using CBT for schizophrenia? __________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Bentall et al (1994) suggests that cognitive therapy may be most effective for patients experiencing their first episode of schizophrenia.
o Why do you think this is? ______________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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CBT usually has to take place weekly, and can last for months. Therefore it can be costly and time consuming when compared to ECT.
What unique practical issues arise from the use of CBT for schizophrenia which do not apply for its use for other psychological conditions?_________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
However, it seems that CBT is most effective when combined with medication. Why might this be? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
