Schizophrenia

1
Schizophrenia
Treatments
2
ECT

• Electro-convulsive therapy (ECT) was widely used
  for Schizophrenia in the 1950s.
• A small current of 0.6 amps is passed through the
  brain, for about half a second.
• This causes a seizure (similar to epilepsy) which
  lasts for about a minute.
• ECT is usually given 3 times per week for up to 5
  weeks.
• Muscle relaxant drugs are used to prevent full
  convulsions, along with anaesthetic to calm the
  patient.
• For Schizophrenia, the standard ECT treatment is
  unilateral,
• i.e. one electrode on the temple of the
  non-dominant brain hemisphere and one electrode
  in the middle of the forehead.
• One flew over the cuckoo's nest - YouTube

3
ECT

• ECT was used because it was observed that, in
  some patients with epilepsy, psychotic symptoms
  and seizures occur alternately i.e. when the
  patient has seizures there are no psychotic
  symptoms, but psychotic symptoms appear when
  seizures are controlled.
• Also it was noted that when a Diabetic patients
  was accidentally overdosed on insulin and had
  massive fits as a result all psychotic symptoms
  disappeared.
•  

4
ECT

• Research evidence, criticism and evaluation
• ECT in England today Psychiatrists in England
  today do not consider it to be an effective
  treatment for Schizophrenia, although it is
  effective for profoundly depressed people who do
  not respond to drug treatment or are at high risk
  of suicide, However, there are schizophrenic
  patients who are also drug resistant or
  experiencing or worried about drug side-effects.
  The overuse of ECT to control very disturbed
  patients in the 50s and 60s is a major factor in
  its lack of use today and also raises serious
  ethical issues, such as a lack of informed
  consent.
•  
• ECT world-wide. Psychiatrists in other countries
  (e.g. India, Japan, Nigeria, Iran) may still use
  ECT for some patients with Schizophrenia,
  sometimes without anaesthetic.
  (Discussion point more repressive societies?)

5
ECT

• Research study Khalilian (2006)
• Khalilian argues that too little attention is
  paid to patients with negative symptoms, since
  Neuroleptic drugs are more effective for
  controlling positive symptoms such as
  hallucinations.
• He proposes that ECT in combination with drug
  therapy might be effective for patients with
  negative symptoms.
• ECT might enhance permeability through the blood
  brain barrier (BBB) so that clozapine can pass
  through and act on the brain tissue.
• This avoids high oral doses of clozapine, which
  leads to side-effects on other organs of the
  body.

6
ECT

• Method
• Khalilian conducted in a small placebo-controlled
  trial of drug-resistant patients. 18
  participants were assigned to 3 treatment groups
  clozapine alone, ECT alone and a combination
  clozapine and ECT.
• He gained written informed consent from patients
  before treatment (Can psychotic patients give
  consent? Diminished responsibility?). A reliable
  test, the Positive and Negative Syndrome Scale,
  (PANSS) was to assess functioning before and
  after treatment a matched pairs design was based
  on functioning.
• Anaesthetic was used this also acted as a
  control so that the clozapine alone group did not
  realise they had not had ECT.
• Findings Combination therapy was superior to
  either therapy on its own significant
  improvement was found in 71 combination
  treatment patients compared to 40 having ECT
  alone and 46 clozapine alone. No adverse
  effects were found.
• However, Khalilian admits that the number of
  patients was small and the duration of remission
  was not studied.
• Can you work out the A02? Memory loss, ethics,
  just biological, not really sure why it works.

7
Chemotherapy

• Medications/ Chemotherapy - Drug treatments
• Medication
• to improve your concentration
• to relieve symptoms such as insomnia,
  nervousness, depression, fears, voices, feelings
  of suspicion, and confused thinking

8
Chemotherapy

• The Biological Approach explains mental disorders
  in terms of abnormalities of the central nervous
  system, i.e. that there is something wrong with
  the workings of the brain. For example,
  Schizophrenia has been explained as being caused
  by an excess of the neurotransmitter dopamine.
  This suggests that drugs which alter levels of
  the various neurotransmitters, by blocking
  receptor sites, inhibiting reuptake or improving
  the break down of molecules following release for
  example may be effective in alleviating symptoms.

9
Chemotherapy

• The Biological Approach explains mental disorders
  in terms of abnormalities of the central nervous
  system, i.e. that there is something wrong with
  the workings of the brain. For example,
  Schizophrenia has been explained as being caused
  by an excess of the neurotransmitter dopamine.
  This suggests that drugs which alter levels of
  the various neurotransmitters, by blocking
  receptor sites, inhibiting reuptake or improving
  the break down of molecules following release for
  example may be effective in alleviating symptoms.

10
Key Terms

• Agonists Drugs that increase Neurotransmitter
  availability, e.g. stimulants.
• Antagonist Drugs that reduce Neurotransmitter
  availability, e.g. Blockers.
• Anti psychotics Drugs that reduce
  Neurotransmitter availability, e.g. Antagonists
  or Blockers.
• Neuroleptics Another name for Antipsychotics.

11
Key Terms

• Typical Antipsychotic drugs Conventional
  Antipsychotics (1950s) that reduce Dopamine
  only. Also they usually only reduce positive
  symptoms. They are very likely to cause the side
  effect of Tardive Dyskinesia in 20-30 of users.
• Atypical Antipsychotic drugs Newer
  Antipsychotics (1990s) that reduce Dopamine and
  Serotonin. Also they reduce positive and negative
  symptoms. They are much less likely to cause the
  side effect of Tardive Dyskinesia. Although more
  likely to cause Agranulocytosis.
• Tardive Dyskinesia is a difficult-to-treat form
  of Dyskinesia (disorder resulting in involuntary,
  repetitive body movements) that can be Tardive
  (having a slow or belated onset).It frequently
  appears after long-term or high-dose use of
  Typical antipsychotic drugs. Tardive Dyskinesia
  is characterized by repetitive, involuntary,
  purposeless movements, such as grimacing, tongue
  protrusion, lip smacking, puckering and pursing
  of the lips, and rapid eye blinking.

12
Key Terms

• Typical Antipsychotic drugs Conventional
  Antipsychotics (1950s) that reduce Dopamine
  only. Also they usually only reduce positive
  symptoms. They are very likely to cause the side
  effect of Tardive Dyskinesia in 20-30 of users.
• Atypical Antipsychotic drugs Newer
  Antipsychotics (1990s) that reduce Dopamine and
  Serotonin. Also they reduce positive and negative
  symptoms. They are much less likely to cause the
  side effect of Tardive Dyskinesia. Although more
  likely to cause Agranulocytosis.
• Tardive Dyskinesia is a difficult-to-treat form
  of Dyskinesia (disorder resulting in involuntary,
  repetitive body movements) that can be Tardive
  (having a slow or belated onset).It frequently
  appears after long-term or high-dose use of
  Typical antipsychotic drugs. Tardive Dyskinesia
  is characterized by repetitive, involuntary,
  purposeless movements, such as grimacing, tongue
  protrusion, lip smacking, puckering and pursing
  of the lips, and rapid eye blinking.

13
Exam Tip

• Focus on ECT and describe Chemotherapy in less
  detail.
• Base your work on P234-235 in the text book

14
3.Cognitive Therapy

• Over the latter part of the 20th Century, one of
  the most impressive developments in our
  understanding of psychopathology has been our
  evolving insight into cognitive factors that play
  important roles in causing and maintaining
  psychopathology.

15
Key features of Cognitive Therapy include-

• Cognitive therapy is all about learning how our
  our thoughts create our moods.
• In CT we discover that we all have inherent
  tendencies to certain negative thoughts that
  evoke unhappiness and disturbance - especially in
  response to particular trigger situations.
• Once we accept that fact, we can learn to spot
  these negative thoughts as they arise, and then
  challenge and re-think them.

16
Who pioneered Cognitive Therapy?

• Albert Ellis
• Developed one of the first cognitive therapies to
  address how people construe themselves, their
  life and the world (circa 1962)
• He came up with Rational-Emotive Therapy (RET)
  which challenges irrational beliefs and persuades
  patients to set more attainable life goals.

• Aaron Beck
• a medical doctor, psychiatrist and psychoanalyst
  who came to believe that he was not getting
  enough improvement in his patients through
  analysis. (circa 1967)
• He realised that often what was holding back
  patients were negative thoughts such as 'I'll be
  hopeless at that', or 'I'm unlovable', or 'I'm
  stupid'.

17
Contemporary Cognitive Behaviour Therapy (CBT)

• CBT came out from these earlier forms of
  Cognitive Therapies.
• CBT is an intervention for changing both thoughts
  and behaviour, representing an umbrella term for
  many different therapies that share the common
  aim of changing both cognitions and behaviour.
• CBT is generally perceived to be an
  evidence-based, cost-effective form of treatment
  that can be successfully applied to a broad range
  of psychopathologies, including Schizophrenia and
  Depression.

18
Characteristics of a CBT Intervention

• A CBT intervention usually possesses the
  following characteristics-
• The client is encouraged to keep a diary noting
  the occurrence of significant events, associated
  feelings, moods and thoughts in order to
  demonstrate how these might be interlinked.
• With the help of the therapist, the client is
  urged to identify and challenge irrational,
  dysfunctional, or biased thoughts/assumptions
• Clients are given homework in the form of
  behavioural experiments to test whether their
  thoughts and assumptions are accurate and
  rational.
• Clients are trained in new ways of thinking,
  behaving and reacting in situations that may
  evoke their psychopathology.
• Tip- You may want to visit this link to know
  more about how CBT is applied to clients with
  severe disorders and as well on those who suffer
  from negative thinking and stress.
• http//www.netdoctor.co.uk/diseases/depression/cog
  nitivetherapy_000439.htm

19
Evaluation

• Using the handout from the Nursing Times and the
  material on P235, evaluate the appropriateness
  and effectiveness of CBT as a treatment for
  Schizophrenia.

20
Summary Chart