Personality Stability vs. Situation?

Personality Traits vs. States vs. Types 18,000 personality terms to 32 traits to- Big five: – Extraversion (outgoing, sociable, positive) – Neuroticism (prone to negative emotions) – Conscientiousness (organized, efficient, disciplined) – Openness to experience (non-conventional, curious) – Agreeableness (trusting & easygoing with others) 40 to 60% heritable

Situationism Low correlations across situations – Strong vs. weak situations – But-brain differences and heritability Introverts more sensitive to external stimuli More reactive central nervous system Low pain tolerance Underactive Nor-epi system Sensation seeking extraverts

Heritability: Big five correlations Identical twins vs. fraternal twins : Identical Fraternal Reared together Reared apart

Personality Theories Psychoanalytic – Childhood experience, ucs influence, dynamics, conflict, defenses, development and identification Humanistic – Focus on self & self-actualization, existential approach, flow & happiness Social-Cognitive Theory – Beliefs, thoughts & personal constructs, often acquired from social interactions & imitation shape behavior Behavioral Theory – Learning history, self-perception theory, self-control

Disorders Who Gets What?

Defining Abnormality Medical approach Statistical approach Functional approach These reflect two basic views of disorders --brain based --behavior/experience/situation based The “two worlds” of psychiatry

DSM-IV Axis 1: Syndromes (Scz, Depress, etc.) Axis 2: Retardation & Personality Disorders Axis 3: General Medical Condition Axis 4: Social/Environmental Problems Axis 5: Global Assessment & Coping Older classification (primarily of Axis 1 & 2) dichotomized: Neuroses & Psychoses Mood (Dep. Bipolar) vs. Thought (Scz) Disrdr Now replaced by highly elaborated DSM-V

Three Broad Types/Dimensions Personality (Psychopathy…..) Mood (Depression, Bipolar) Thought (Scz. Delusions, Hallucinations)

SCZ Manifestations/Symptoms Positive symptoms: -- Hallucinations – delusions – Disorganized or strange behavior & speech Negative symptoms: – Flat affect & other behavior – Catatonia – Withdrawel from others

Prevalence of Neurotic Disorders by Age Hollingshead & Redlech New Haven Study, 1958

Prevalence of Neurosis by Age & Social Class

Prevalence of Psychosis by Age & Gender

Treatment Duration & Social Class

Psychosis: Age and Social Class

Heritability of Psychosis: Schizophrenia

Scz incidence & poverty/residential area

Some Interim Conclusions Psychoses (focus on SCZ) is a disorder of heredity and/or prenatal environment But it’s also a disorder of poverty (and that may be bidirectional)! Another view of prevalence and recent dramatic changes in prevalence

Deinstitutionalization

Prevalence Schizophrenia: approx. 1% Bipolar Disorder: approx. 1% Depression: approx. M 13% F 21%

Basic Models of Disorder Stress: Functional Disorder -Cognitive & Social Origins Illness: Medical/Biological –Brain-based (synaptic & neural network/connectivity) Mixed Model: Vulnerability  Stress Szasz: Radical Anti-medical Approach

Treatment

Overview Brief History Psychological Treatments Biomedical Treatments Client-Therapist Relationship Is Treatment Effective?

History Earliest history – Mental illness believed to be caused by evil spirits. Hippocrates began to dismantle this. – Treatments were harsh, ineffective Drill holes in skulls to create exits for spirits Make the body horribly uncomfortable for the spirits Purge demons through inducing vomiting

History Middle Ages – Mental illness viewed more like a disease, but not treated well! – Mental institutions were created Purpose: confine “madmen” Included other social “undesirables” Inhumane treatment (shackles and chains)

Beginning of Reform Early to Mid 1800s – Philippe Pinel put in charge of Paris’ hospital system Removed shackles and chains Patients allowed to exercise, venture outside

Beginning of Reform Dorthea Dix – Fought for humane treatment of patients in U.S. 19 th century – Freud’s “talking cure” (Charcot & hypnosis)

Psychological Treatment Overview Treatment involves addressing three major components of the illness: – Biological – Psychological – Social Something to keep in mind: – These three major components are not necessarily black-and-white/separable

Who provides treatment? Clinical psychologists Psychologists Neurologists Psychiatric Nurses Marriage and Family Counselors Social workers School counselors Clergy

Who seeks treatment? People with mental illness, hoping to relieve pain and dysfunction People looking for assistance in recovering from grief, anxiety, confusion, relationship issues and other life challenges…tilted toward – Women – European Americans – Financially well off – People with Health Insurance (which increasingly controls things)!

Psychological Treatments Focused on changing the way the patient thinks and behaves Involves discussion, instruction, training, relationship analysis Over 500 different forms of such treatment – Psychodynamic – Humanistic – Behavioral – Cognitive

Psychodynamic Approaches Illness result of unconscious conflicts developed early in childhood with impact later Defense mechanisms shield from the inner conflict – This can lead to symptoms of mental illness Treatment: Uncovering unconscious desires and conflicts, and resolving them – Integrate thoughts and memories coherently

Psychodynamic Approaches “Working through” the conflict – Transference Used as a therapeutic tool In order to be effective, therapist must remain neutral

Humanistic Approaches Based off of Freud’s “talking cure” However, less focused on basic drives Instead, focus on creating meaning Clients need to take responsibility for their lives and actions, and live in the “here and now”

Humanistic Approaches Client-Centered Therapy (Carl Rogers) – Focuses on achieving self-acceptance – Does not pass judgment, or provide instruction – Aim is to create an environment in which the client feels understood and valued -Requires & elicits a capable client

Humanistic Approach Creating the therapeutic environment – Genuineness- sharing authentic reactions – Unconditional positive regard Non-judgmental, accepting – Empathic Understanding- putting oneself in the patients’ shoes

Behavioral Approaches Reaction to Freud’s psychoanalysis Viewed Freud’s approach as too unscientific Treatment directed at reducing or eliminating problematic behaviors (because behavior is all there is!) Institutional control mechanism (humane?) Approach involves replacing old habits with more effective or adaptive behaviors – Classical conditioning, operant conditioning, modeling

Behavioral Approaches Classical Conditioning Techniques Treatment of Phobias – Extinguish the association between the neutral stimulus and the fearful stimulus – Exposure Therapy Train clients in deep muscle relaxation, pair relaxation with the fearful stimulus Create a hierarchy of progressively more frightening stimuli Systematic desensitization: gradual exposure to the real phobic stimulus

Systematic Desensitization

Behavioral Approaches Operant Conditioning Techniques Token economies – Earn tokens for positive behaviors, which can be exchanged for prizes – Shaping Contingency Management – Strict consequences for certain behaviors Successful for shaping communicative behavior in children with autism (Lovaas) Modeling Techniques – Therapist perceived as role model

Cognitive-Behavioral Approaches Rational Emotive Behavioral Therapy (Albert Ellis) People typically think that an event causes them to behave a certain way – But…beliefs matter – Focused therapy on changing beliefs Teacher-like

Cognitive Therapy Aaron Beck Focused on changing dysfunctional thought Cognitive Restructuring – Challenge a person’s unhealthy beliefs or interpretations – Used persuasion and confrontation – Brief, problem-focused Initially treated depression

Cognitive-Behavioral Therapy Followers of Ellis and Beck blended the two therapies to form CBT Focus on addressing problems the patient wishes to solve Intimate relationship between behavior and thought (self perception theory!) Often clients are assigned homework – Practice new ways skills or thought techniques

Eclecticism Modern therapy tends to blend aspects from many of these perspectives Makes sense, since there are often many causes of mental illness

Client-Therapist Relationship Therapeutic Alliance – Support Trust Hope Understanding

Group Therapies Often groups are chosen because they share similar problems (e.g., Alcoholics Anonymous) Focus on the shared problems, less on the individuals’ emotions Advantages – Social support – Share advice, information – Observe other peoples’ successes – Realize that not alone, others share similar problems – Economic advantage

Couple and Family Therapy Views the family or relationship as a complex system – One person’s negative behavior or cognitions may reflect a larger issue for the entire family or relationship Can be extended to treating children who have little control (work with family to change situation/mileau)

Biomedical Treatments The Early Gruesome Years Trephination – Allowed “evil spirits” to escape the skull Hot or Cold Baths Spinning

Biomedical Treatments Psychosurgery Prefrontal Lobotomy – Sever connections between thalamus and frontal lobes – Disrupted higher cognitive functions Modern techniques are more precise and used as a last resort treatment

Electroconvulsive Therapy (ECT) Brief electrical current passed through the brain causing a convulsive seizure Originally developed to treat schizophrenia Very effective for treating severe depression (70-90% effective) Memory impairment Mechanisms are not known

Different Therapies for Different Conditions (& Sometimes a Mix) Medical: Brain targeted drug interventions examples: --SCZ: Dopamine receptor blockers (the better the block the more effective it is) --Other neurotransmitters involved as well --Depression: ex. Norepinephrine uptake or release+, Serotonin release+, & a host of other neurotransmitter controls involved -- Electro-convulsive shock therapy!

Pharmacological Treatments Psychotropic drugs – Not only helped treat patients, but also further understanding of the illness

Pharmacological Treatments Antipsychotics – Treat positive symptoms of schizophrenia – Not effective for treating the negative symptoms – Most common are Thorazine, Haldol and Stelazine Block dopamine receptors in particular brain pathways Atypical Antipsychotics – Treat negative symptoms of schizophrenia, too – Risperdal, Clozaril, Seroquel

Antipsychotics and Deinstitutionalization Movement in the 1950s shortly after development of the first antipsychotics – Aimed to provide less expensive mental health care at local community centers instead of institutions Pros – Fewer people spending their lives in institutions – Shorter stays – Thomas Szasz argument Downside – Lack of appropriate care in community settings – Lack of integration into the community (support services, employment) – Many mentally ill are now homeless, or in jail

The next slides The next six slides are for informational purposes to show the variety and nature of particular psycho-pharmacological approaches but should not be memorized!

Antidepressants Monoamine Oxidase Inhibitors (MAOIs) – Nardil Tricyclic antidepressants – Tofranil Increase serotonin and norephinephrine for synaptic transmission Both very effective (significant improvement in 65% of patients) – Many negative side effects

Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) – Prozac, Zoloft, Paxil, Celexa, Lexapro – Minimally effect dopamine and norepinephrine, and maximally effect serotonin Reduced side effects – Most commonly prescribed Atypical Antidepressants – Effect serotonin, norepinephrine and dopamine in various ways Wellbutrin (fewer side effects)

Antidepressants Downside – Takes a while before effective (a month) – Trial-and-error – Side effects Weight gain, nausea, diarrhea, insomnia, reduced sexual desire or response

Mood Stabilizers Treat symptoms of bipolar disorder Lithium carbonate – Treats manic episodes as well as depressive episodes – Side Effects Weight gain, sedation, dry mouth, tremors – Adherence to medication Often patients do not wish to treat mania, only depression – Lethal at high doses – Effective for 60 – 70% of patients

Anxiolytic Medications Treat anxiety disorders Increase neurotransmission of GABA Beta Blockers Benzodiazepines Tricyclic Antidepressants and SSRIs

Anxiolytic Medications Beta Blockers – Controls autonomic arousal Benzodiazepines – Valium, Xanax, Klonopin – Short term treatments – Highly addictive – Interact dangerously with alcohol – New drugs are being developed to reduce these negative side effects – Rebound effect

Medication: Costs and Benefits Can be highly effective Only treats and controls the symptoms – Relapse Requires trial-and-error for correct drug and correct dosage Side effects – Reduce adherence to medication Overprescription

Outcomes: Improvement with Drugs vs. Placebos

Emerging Biomedical Treatments Repetitive TMS – Areas of the brain stimulated with magnetic coil for minutes over several weeks – Effective for medication- resistant depression – No cognitive side effects Deep Brain Stimulation – Electrodes implanted in brain

Combined Treatments Most therapists use a combination of treatments – Drug treatments for short-term effects – Therapy for long-term effects

Evaluating the Efficacy of Treatments Randomized Clinical Trial (RCT) – Treatment group – Placebo group – Random assignment – Symptoms and severity similar across participants – Follow participants over several months

Efficacy vs. Utility Difficult to run RCT for psychotherapy – Waitlist – Manualized (prescribed) Therapy Controlled studies allow researchers to come to conclusions about the efficacy of particular treatments In many circumstances, patients have more than one illness Also, therapists typically use more than one approach

Is therapy effective? A meta-analysis found that 80% of patients who received treatment fared better than those without

Are all Therapies Equally Effective?

Who provides the most effective psychological treatment? Number of years of practice? – Not necessarily Professional credentials? – No The rapport between therapist and client seems to be strongest predictor – Respect, trust, comfort

Who is most likely to benefit from treatment? Strong alliance with therapist Motivated Optimistic More effective with more therapy

Are All Treatments Equally Effective? A depression meta-analysis shows… – Drug treatment alone 55% effective – Therapy alone 52% effective – Drug AND therapy 85% effective! (New England Journal of Medicine, 2000)

Are all Treatments Equally Effective? Treatment more effective than no treatment Combining treatments appears most beneficial Some therapies seem particularly effective for specific disorders – Exposure therapy  phobias

Moral of the Story Treatment is effective! Modern treatments are much more effective and humane than past treatments The relationship between therapist and client really matters!

Recent Reconceptualization Some people are able to cognitively overcome even serious levels of disorders – Available to psychotherapy – Find meaning in some symptoms – Able to live normally or quasi-normally – Example in Nash film and in today’s reading

If you feel you need help… Seek it! Ask for advice, or set up an appointment with a counselor. It’s not a weakness. Make sure the therapist is a good match for you! Remember it can take time and you may face some setbacks, but also… Remember treatment is effective! Most people improve!

Overview The “Two Worlds” of psychiatry approach is flawed. The brain is the source of behavior and thus a possible route of change via medical intervention, but…. Behavior and experience can modify the brain, thus psychotherapy, while targeting behavior, also “tunes the engine” by acting on the brain.