PSY 100Y5
TREATMENT OF DISORDERS LECTURE
DR. KIRK R. BLANKSTEIN
OUTLINE
 Overview
 Biopsychosocial Model
Biopsychosocial Assessment
Multifaceted Interventions
(Biological, Psychological, Social)
 How Does Treatment Differ From Friendship?
 SCHIZOPHRENIA: Causes and Treatment
 Review of Symptoms and Subtypes
 A Diathesis-Stress Model of Causes

Biological Treatment
 Psychosocial Interventions
 Civil Commitment in Ontario
 ANXIETY: Causes and Treatment
 Review of Symptoms and Subtypes
 An Integrated Causal Model
 Panic Disorder
 Test Anxiety?
 Cognitive Behaviour Therapy
Psychological
factors
personality
cognitive style
The
BIOPSYCHOSOCIAL
Model
social skills
Biological
factors
symptoms of
psychopathology
(diagnosis)
brain structure
neurochemistry
hormones
autonomic nervous
system functions
Social factors
marital adjustment
family functioning
peer relationships
work & school
satisfaction
The clinician’s conceptual approach to a person’s problem will
determine the selection of assessment instruments. This figure
lists examples of variables that might be considered within each
broad conceptual level.
Psychological
factors
Levels of Analysis in
ASSESSMENT
personality
cognitive style
social skills
Biological
factors
symptoms of
psychopathology
(diagnosis)
brain structure
neurochemistry
hormones
autonomic nervous
system functions
Social factors
marital adjustment
family functioning
peer relationships
work & school
satisfaction
The clinician’s conceptual approach to a person’s problem will
determine the selection of assessment instruments. This figure
lists examples of variables that might be considered within each
broad conceptual level.
Modes of Assessment
 Clinical psychologists typically employ three primary
modes of assessment:
INTERVIEWS: gather information
from the person’s point of view.
TESTS: can be “objective” or
“projective.
DIRECT OBSERVATION: may be
used as “signs” or “samples” of
behavior.
The model or perspective subscribed
to by the assessor influences the
assessment:
 e.g., the interview conducted by a
psychoanalytically oriented clinician
is very different from a behavior
therapist’s interview.
CASE FORMULATION: The therapist’s
hypothesis about the nature of the psychological
mechanisms underlying the client’s difficulties
DOES THE CASE FORMULATION
IMPROVE TREATMENT OUTCOME?
DIFFERS FROM BEHAVIOURAL
ANALYSIS IN PLACING MUCH MORE
EMPHASIS ON UNDERLYING
COGNITIONS
VIEWS CLIENT’S PROBLEMS AS
EXISTING AT TWO LEVELS:
 OVERT DIFFICULTIES=the actual problems in living
that clients seek help for (e.g., depression, relationship
difficulties)
 UNDERLYING MECHANISMS=the underlying (central)
psychological mechanisms that produce and maintain the
overt difficulties (e.g., dysfunctional attitudes or beliefs
about the self, others, and the world; schemas or networks
of related dysfunctional attitudes)
CRITICAL
THINKING
• DO YOU THINK THAT
THERE ARE
ADVANTAGES ( AND
DISADVANTAGES) IN
GETTING HELP FOR
PSYCHOLOGICAL
PROBLEMS FROM A
FRIEND RATHER THAN
FROM A PROFESSIONAL
THERAPIST? WHAT ARE
THE ADVANTAGES (AND
DISADVANTAGES) OF
GETTING HELP FROM
THE PROFESSIONAL
THERAPIST RATHER
THAN FROM YOUR
FRIEND?
 Advantages of  Advantages of
getting help
getting help from
from a friend
a therapist rather
rather than a
than from a
therapist
friend
 COST
 LESS STIGMA
 CONVENIENCE
 INTIMATE
KNOWLEDGE
 EXPERT OPINION
 KNOWLEDGE OF
RESOURCES
 UNDERSTANDING
OF SERIOUS
PROBLEMS

CONFIDENTIALITY
 OBJECTIVITY
 SEPARATION
FROM PERSONAL
TARASOFF AND THE
DUTY TO WARN AND
PROTECT POTENTIAL
VICTIMS
 PROSENJIT PODDAR KILLED
TATIANA TARASOFF ON
OCTOBER 27, 1969.
 THE CALIFORNIA SUPREME
COURT RULED THAT PODDAR’S
THERAPIST (A CLINICAL
PSYCHOLOGIST AT THE
UNIVERSITY OF CALIFORNIA AT
BERKELEY) SHOULD HAVE
WARNED TARASOFF THAT HER
LIFE MIGHT BE IN DANGER.
Psychoanalysis
FREUD’S CLASSIC
TREATMENT FOCUSES ON
CHILDHOOD MEMORIES AND
UNCONSCIOUS CONFLICTS;
TECHNIQUES INCLUDE FREE
ASSOCIATION, DREAM
ANALYSIS, TRANSFERENCE,
AND INTERPRETATION;
SEVERAL MEETINGS A WEEK
FOR SEVERAL YEARS;
THERAPIST ALOOF.
Psychodynamic
Psychotherapy
MANY VARIATIONS OF THIS
SHORT-TERM INSIGHTORIENTED TREATMENT;
THERAPIST IS MORE
DIRECTIVE OR
CONFRONTATIONAL IN
INTERPRETING DEFENSES;
TREATMENT FOCUSES ON
SINGLE ISSUE OR THEME
Ego Analysis
PSYCHODYNAMIC
TREATMENTS DEVELOPED
BY SULLIVAN, HORNEY,
ERIKSON, AND OTHER
FOLLOWERS OF FREUD;
INSIGHT IS GOAL BUT THE
PRESENT, THE CONSCIOUS
MIND, AND SOCIAL
RELATIONSHIPS (THE
EGO) CONSIDERED BY
MORE ACTIVE, WARM
THERAPIST.
LONG-TERM BUT SHORTER
THAN PSYCHOANALYSIS
Criteria for a Panic Attack
A discrete period of intense fear or discomfort in which
four (or more) of the following symptoms developed
abruptly and reached a peak within 10 minutes.
• palpitations, pounding heart, accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath/ smothering
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, faint or lightheaded
• derealization or depersonalization
• fear of losing control or going crazy
• fear of dying
• paresthesias (numbness or tingling sensations)
• chills or hot flushes
1) Cued or Situationally Bound
TYPES
2) Situationally Predisposed
3) Unexpected (Uncued)
Typical Situations Avoided
by a Person with
Agoraphobia
• Shopping
malls
• Cars
• Trains
• Buses
• Subways
• Wide streets
• Tunnels
• Restaurants
• Theatres
•
•
•
•
•
•
•
Supermarkets
Stores
Crowds
Planes
Elevators
Escalators
Waiting in
line
• Being far
from home
Anxiety and Panic:
An Integrated Causal Model
Biological Factors
• genetics
• neurobiology
(BIS, FFS)
Psychological Factors
• sense of controllability
• conditioning
• cognitions/expectancies of
danger
• anxiety sensitivity
Social/Environmental
Factors
• stressful life
events
• social
pressures to
succeed
Differential Diagnosis
Anxiety
Disorder
Focus of the Anxiety
GAD
 minor everyday events
Panic
Disorder
 the next panic attack
Specific
Phobia
 specific situations/objects
Social
Phobia
 embarrassment/evaluation in
social situations
PTSD
 avoidance of thoughts/images of
past trauma
OCD
 avoidance of intrusive thoughts
or neutralization through rituals
Panic Disorder with and
without Agoraphobia
Panic Disorder (PD)
• recurrent unexpected panic attacks
• one month of anticipatory anxiety OR a
significant change in behaviour related to
the attacks
Panic Disorder with Agoraphobia (PDA)
• anxiety about being in places or
situations from which escape might be
difficult or embarrassing in the event of a
panic attack
• situations are avoided or are endured
with marked distress or anxiety about
having a panic attack OR require the
presence of a companion
Overview: Cognitive-Behavioral
Treatment Strategies
1. Psychoeducation
2. Rationale/Goals for Treatment
– three components of fear/anxiety
3. Exposure (+Response prevention ?)
– to feared objects, situations
– imaginal vs. in vivo
– hierarchy
4.
5.
6.
7.
8.
Modeling
Interoceptive Exposure
Breathing Retraining
Deep Muscle Relaxation
Cognitive Therapy (Restructuring)
– probability overestimation, catastrophic
cognitions, self-talk
Overview: Cognitive-Behavioral
Treatment Strategies -- continued
9.
10.
11.
12.
Social Skills/Assertiveness Training
Coping Skills
Problem Solving
Homework
– handouts, tapes, self monitoring
13. Pharmacotherapy
– SSRI’s, high potency benzodiazepines,
TCA’s
**Variation: individual vs. group
Treatment for
Panic Disorder
1. Exposure to Agoraphobic
Situations
2. Interoceptive Exposure
3. Cognitive Therapy
4. Breathing Retraining
5. Relaxation Therapy
6. Medication (imipramine,
alprazolam)
Principles of Effective
Exposure
•
•
•
•
•
•
•
•
•
•
•
•
•
Duration of Exposure
Massed vs. Spaced Exposure
Graduated Exposure vs. Flooding
Structuring Exposure Sessions in Advance
Predictability
Perceived Control
Distraction, Safety Signals, & Overprotective
Behaviors
Imaginal vs. in-vivo Exposure
Fighting the Fear
Focus of Attention (e.g., on finding an escape)
Measuring Success
Integrating Exposure and other Strategies
Overlearning
Exposure Hierarchies:
Example of Height Phobia
1. Standing on a chair
2. Standing on a table
3. Standing ten steps up on a ladder
4. Looking out of a 12th floor closed window
5. Looking over a second floor open balcony
6. Looking over a fifth floor open balcony
7. Looking over a tenth floor open balcony with
water below
8. Looking over a tenth floor open balcony with
concrete below
9. Going up the CN Tower & looking out the
window
10. Going up the CN Tower and stepping out onto
the observation deck
Typical Situations Avoided
by a Person with
Agoraphobia
• Shopping
malls
• Cars
• Trains
• Buses
• Subways
• Wide streets
• Tunnels
• Restaurants
• Theatres
•
•
•
•
•
•
•
Supermarkets
Stores
Crowds
Planes
Elevators
Escalators
Waiting in
line
• Being far
from home
Beck’s Cognitive- Behavioral Therapy:
Three-Column Technique
EVENT
AUTOMATIC
NEGATIVE
THOUGHTS
RATIONAL REPLIES
My boyfriend
didn’t call on
Friday.
He’s losing interest
in me.
He’ll leave me.
What’s the error? I can’t read his
mind or foretell the future.
What’s the evidence? He doesn’t call
as much as he used to.
However,he’s been very busyat
work.
Could I collect more information? I
could ask him how he thinks our
relationship is going.
Is there another way to look at it? He’s
probably just busy and couldn’t
call. Even if he is losing interest,
however, that doesn’t mean he’ll
leave me. Maybe we can improve
things.
So what? Even if the worst is true and
he did leave me, I could survive.
I’ve been on my own before, and
even if it was hard at the time, it
wasn’t impossible.
I feel rejected.
It means I’m
undesirable. No
one will ever love
me. I’ll always be
alone.
(Ask the same kinds of
questions as those listed
above, and try to come up
with more realistic
thoughts.)
MEICHENBAUM’S
CONSTRUCTIVIST COGNITIVEBEHAVIORAL TREATMENT
MODEL








Donald Meichenbaum has developed several manualized and empirically-supported
treatments using cognitive-behavioral approaches. His approach is partly based on the
literature on common factors in psychotherapy and his interests in the psychotherapy
integration movement. The following tasks of psychotherapy form the core of his
constructivist cognitive-behavioral treatment approach; he also views these as the
common elements in all successful therapy.
DEVELOP A THERAPEUTIC ALLIANCE AND HELP CLIENTS TELL THEIR
STORIES.
EDUCATE CLIENTS ABOUT THE CLINICAL PROBLEM.
HELP CLIENTS RECONCEPTUALIZE THEIR “PROBLEMS” IN A MORE
HOPEFUL FASHION.
ENSURE THAT CLIENTS HAVE COPING SKILLS.
ENCOURAGE CLIENTS TO PERFORM “PERSONAL EXPERIMENTS”.
ENSURE THAT CLIENTS TAKE CREDIT FOR CHANGES THEY HAVE
BROUGHT ABOUT.
CONDUCT RELAPSE PREVENTION.


TASK: Using this framework, evaluate the therapies studied in this course to
determine which have these elements in common.
The constructivist narrative perspective which Meichenbaum adds to traditional
cognitive therapy is based in a view of people as “meaning-making agents” who
construct their own stories to explain their lives and experiences. In contrast to
traditional Cognitive Therapy, Meichenbaum’s approach is less structured, more
exploratory, and more discovery-oriented. Clients are assisted in telling their stories and
in creating new stories through therapy.
Prevalence of Schizophrenia
– Varies depending on whether a broad (Bleuler)
or narrow (Kraepelin, Schneider) definition of
the disorder is used. (DSM-IV is considered a
middle-of-the-road compromise).
– Schizophrenia occurs:
– worldwide at a lifetime prevalence rate
of about 1% (morbidity risk)
• range: 0.2 to 2.0%
– equally in males and females
– earlier (at least 5 years) for males than
females
• men hospitalized more often and prognosis is poorer
– usually in the late teens or early 20s, but
as late as the 50s
•
Schizophrenia and related psychoses were not included in
the Ontario Health Survey (1990) Mental Health
Supplement because the sample did not identify enough
people to permit meaningful study.
TYPES OF DELUSIONS
Fixed beliefs with no basis in reality
There are several types of delusions that are
often woven together in a complex and
frightening system of beliefs
 PERSECUTORY delusions
delusions of BEING
CONTROLLED
THOUGHT BROADCASTING
THOUGHT INSERTION
THOUGHT WITHDRAWL
delusions of GUILT or SIN
SOMATIC delusions
GRANDIOSE delusions
Schizophrenia
DIATHESES
STRESSORS
•
•
•
•
•
•
Genetic factors
Physical trauma
prenatally or
during birth
Structural
abnormalities of
the brain
Abnormalities in
neurotransmitter
systems
Psychosis-prone
personality
•
•
Physical trauma,
prenatally or during
birth
Chronic
psychological and
social stressors and
environmental
hazards associated
with urban living and
poverty
Family environment
with high Expressed
Emotion
Genetic Factors
and Schizophrenia
 The closer a person’s biological relationship to someone
diagnosed with schizophrenia, the greater that person’s
risk of developing schizophrenia or one of the
schizophrenia spectrum disorders.
 The evidence is clear on several other points:
 Schizophrenia “runs” or aggregates in families.
This aggregation is found regardless of the type of
research methodology (family, adoption or twin studies)
used or the country in which the study is performed.
 In many cases a vulnerability that predisposes a
person to schizophrenia (scientists don’t know exactly
what) is genetically transmitted.
Genes alone are not sufficient to account for the
development of schizophrenia.
•
Today, most investigators believe that the genetic contribution to the
majority of cases of schizophrenia is polygenic, meaning that a
mosaic of different genes act in concert to influence the
development, probability, and severity of schizophrenia.
PSYCHOSOCIAL FACTORS AND
SCHIZOPHRENIA
The two psychosocial factors receiving the most attention in
the study of schizophrenia are: socioeconomic class and
associated stressors; and family environment and family
communication patterns.
Explanations for the disproportionate rate
of schizophrenia among urban and
lower SES groups include:
 the social drift hypothesis, which
suggests that, as people develop
schizophrenic symptoms, they gradually
slide down the socioeconomic ladder;
and
 the breeder or social causation
hypothesis, which suggests that social
strains and environmental hazards
breed schizophrenic episodes in
vulnerable individuals.
 Many schizophrenic people come from families
that are socially and economically advantaged.
 Despite suffering psychotic symptoms for years
on end, many schizophrenics do not drift into lives
of poverty or marginality.
The Role of “EXPRESSED
EMOTION” and Schizophrenia
How do you think you would act if you lived with a person who had schizophrenia?
Would you feel afraid? Would you be a nag? Would you challenge the person
to become more socially involved or would you feel sorry for the person?
There is a strong relation between a family’s emotional
overinvolvement and the rate at which patients suffer
relapses of schizophrenia.
EXPRESSED EMOTION usually involves high levels of
 criticism (“You don”t do anything but sit in front of the TV”
 hostility (“I’m sick and tired of your craziness”) and
 overinvolvement (“I’ll go downtown with you so we can have time
together.” or “Don’t you realize how hard I try to help you out?”).
How might EE lead to relapse?
Perhaps schizophrenics are sensitive
to environmental stimulation, particularly social criticism, which may
drive up their levels of psychophysiological arousal. Under this
heightened arousal, they might lose some of their already-impaired
ability to process information accurately. Result? They feel bombarded
with negative stimuli, their symptoms increase, and soon their condition
deteriorates into a full-blown episode of psychosis. Family stressors
involving EE could also combine with other life events to heighten the
risk of relapse.
ONTARIO’S FIRST MENTAL HOSPITAL WAS
ESTABLISHED IN THE OLD YORK (TORONTO)
JAIL, IN JANUARY, 1841.
 IT WAS ULTIMATELY ESTABLISHED AS THE
NOTORIOUS “999” ON QUEEN STREET IN 1850.
 OFFICIAL TITLE: “LUNATIC ASYLUM”
 LONDON PSYCHIATRIC HOSPITAL WAS CALLED THE:
 “IDIOT BRANCH”
 ORILLIA PSYCHIATRIC HOSPITAL WAS CALLED THE:
 “HOSPITAL FOR IDIOTS AND IMBECILES”
Chronic
Social Breakdown
Syndrome
 APATHY
 DEPENDENCY
 SOCIAL
WITHDRAWL
Antipsychotic (Neuroleptic)
Treatment of Schizophrenia
 The phenothiazines, the primary treatment for
schizophrenia,
 relieve positive symptoms for 60 to 70% of
patients (however, fewer than 30% respond well
enough to live in communities entirely on their
own); and
 cause several kinds of serious side effects (e.g.,
extra-pyramidal symptoms such as
Parkinsonism, tardive dyskinesia, and
neuroleptic malignant syndrome)
 Newer, atypical antipsychotic drugs (e.g.,
clozapine):
•
 relieve negative symptoms as well as positive
symptoms; and
 help some patients who are resistant to the
phenothiazines.
It is a mistake in my view to think about the treatment of
schizophrenia in purely biological terms. Drugs are usually
necessary for controlling symptoms, but they cannot
make a new life for patients or teach them to cope
with the negative consequences of the disorder.
Psychosocial Treatment
The most effective psychosocial treatments for
schizophrenia focus on:
 training in self-help and social skills
 family therapy in which families are taught how to
deal with patients when they return home
 psychosocial rehabilitation that helps patients live in
communities by strengthening their independent living
skills and creating more supportive environments
 vocational rehabilitation
 The very best programs also include:
 individual case managers who serve as advocates and
help patients obtain necessary services
 social support that “wraps around” patients and holds
them in the community
 peer support groups
 “safe houses”
 individualized plans to help clients avoid or manage
crises
patients help write proactive crisis plan
 specific vocational rehabilitation plan identifying
occupational goals and needed skills
“job clubs” or transitional employment
 interpersonal work skills
Prevention?
Stopping Relapse in Young
Schizophrenic Patients
• Although scientists have discovered no effective
ways to prevent schizophrenia, psychosocial
rehabilitation coupled with regular medication
comes the closest to constituting a form of
secondary prevention.
• Many programs pay special attention to serving
relatively young schizophrenic patients who are
not yet chronically disabled from the disorder.
 The search for more effective
treatment must include the pursuit of
new medications and the discovery of
how psychosocial and cultural
stressors and buffers can be changed
to lessen the incidence of
schizophrenia.
True reform is up to all of us”
By Scott Simmie,
The Toronto Star, October 10, 1998
 MONEY
 HOUSING
 ALTERNATIVE
BUSINESSES
 COMMUNITY
MENTAL HEALTH
CENTRES
 INCOME SUPPORTS
 PROVINCIAL
PSYCHIATRIC
HOSPITALS
 THE DOCTORS
 RISK ASSESSMENT
 DIVERSION
PROGRAMS
 DRUG COVERAGE
EXTENSION
 ANTI-STIGMA
CAMPAIGN
 THE AGENCIES
 EMPLOYERS
 COMMUNITY
TREATMENT ORDERS
 CONSUMERS
 “BEST” DRUGS FIRST
 THE MEDIA
 KIDS--A CLEAR
PRIORITY
 BUILDING A SYSTEM
 CRISIS CENTRES--A
PLACE TO GO
 CRISIS LINES--A
PLACE TO CALL
 THE POLICE
 THE PUBLIC