FACULTY OF APPLIED SOCIAL SCIENCES

SEMESTER MAY 2019

ABPK3203

PSYCHOLOGY OF LEARNING

MATRICULATION NO : 730307125428001
IDENTITY CARD NO. : 730307125428
TELEPHONE NO. : 0128206704
E-MAIL : dinnadaisy@hotmail.com
LEARNING CENTRE : SABAH LEARNING CENTRE
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TABLE OF CONTENTS
Pages

Introduction ……………...………..………..………..………………………. 3

Explanation of biological and psychosocial interventions for

psychological disorder …………………..…………….…..………..…..……. 4

Proposal of treatment plan for bipolar disorder (biological intervention) …….. 7

Justification of proposed treatment plan……..………..………..……………. 9

Discussion on how psychosocial intervention might be a better or worst

option to treat bipolar disorder……..………..………..……………,.………. 11

Conclusion ……………………………………………….……………….... 13

References ……………………………………………….……………….... 14

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Introduction
The report brings about the discussion on developments in the acute and long-term
treatment of bipolar disorder and identify promising future routes to therapeutic
innovation. Overall, advances in drug treatment remain quite modest. Antipsychotic
drugs are effective in the acute treatment of mania; their efficacy in the treatment of
depression is variable with the clearest evidence for quetiapine. (Cipriani, Barbui &
Salanti, 2011)
Despite their widespread use, considerable uncertainty and controversy remains about the
use of antidepressant drugs in the management of depressive episodes. Lithium has the
strongest evidence for long-term relapse prevention; the evidence for anticonvulsants
such as divalproex and lamotrigine is less robust and there is much uncertainty about the
longer term benefits of antipsychotics. Substantial progress has been made in the
development and assessment of adjunctive psychosocial interventions. (Cousins, Butts &
Young, 2009)
Long-term maintenance and possibly acute stabilisation of depression can be enhanced
by the combination of psychosocial treatments with drugs. The development of future
treatments should consider both the neurobiological and psychosocial mechanisms
underlying the disorder. We should continue to repurpose treatments and to recognise the
role of serendipity. (Strockmeier, 2003)
We should also investigate optimum combinations of pharmacological and
psychotherapeutic treatments at different stages of the illness. Clarification of the
mechanisms by which different treatments affect sleep and circadian rhythms and their
relation with daily mood fluctuations is likely to help with the treatment selection for
individual patients. To be economically viable, existing psychotherapy protocols need to
be made briefer and more efficient for improved scalability and sustainability in
widespread implementation. (Dilsaver, 2011)

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Explanation of biological and psychosocial interventions for psychological disorder

Clinical Interventions is aimed to modify a person’s behaviour, cognition, or emotional

condition. An intervention process in treating a psychological disorder may either opt for
either biological intervention approach or psychosocial intervention approach. Both
method are aimed to making changes to their behaviour or emotional state. (Dilsaver,
2011)
As every individual are different therefore treatments for psychological disorder may
varies, taking into account their situation and symptoms here onwards then to be consider
the best interventions to be taken, as some mental illness may find medications to be the
effective intervention and while others seek the help of psychotherapy. Which brings us
to discuss at the two intervention in clinical psychology, which are: (OUM, 2011)
1) Biological Intervention
In biological intervention, it explains that mental illness as having physical causes which
requires physical treatment. Treating psychological disorder with biological intervention
we can look at the four main interventions here, which are psychopharmacotherapy,
Electroconvulsive therapy, transcranial magnetic stimulation and psychosurgery. All of
which these biological intervention treatments are to treat the imbalance chemical in the
brain, let’s look at each of these treatment in depth. (Gitlin, Swendsen, Heller &
Hammen, 1995)
a) The term psychopharmacotherapy, refers to taking prescribed drug treatment for
symptoms of psychological disorder. Pharmacotherapy has been the main
treatment in treating schizophrenia, bipolar disorder, anxiety and clinical
depression. Examples of these prescribed medication, may seem familiar to us
especially when we watch many medical related movies or have any friends or
relatives that have psychological disorder being prescribed of such medication.
These psychiatric drugs used in the treatment psychological disorders are for
antidepressants, to reduce level of depressions; Antimanic which is used to treat
patients with bipolar disorder, helping to moderate mental and motor activity, as

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well to decrease delusions from the patients manic episode, such as Olanzapine;
Antipsychotic drugs are used to manage psychological disorders such as
hallucinations, disorganised thinking, and agitation; Psychostimulants are used in
patients with Attention Deficit Hyperactivity Disorder, where the prescribed
medications assist in increasing the level of alertness. (OUM, 2011)
As patients that is treated with psychopharmacotherapy method, the medication
used does not cure the patients disorder, but only modifies the specific symptoms.
Therefore patient that is treated with psychopharmacotherapy may also be treated
together with psychotherapy method in removing the negative symptoms of the
psychological disorders.
b) Electroconvulsive Therapy (ECT) is used to treat extremely severe cases of
psychotic disorder that did not respond to other forms of intervention.
Electroconvulsive Therapy procedure works by administering small electric
currents that are passed through the brain to trigger a brief seizure to the patient,
which cause changes in the brain chemistry resulting to reverse symptoms of a
certain psychotic disorder. Research has shown that ECT procedures blocks stress
hormones, when serotonin levels increased hence promotes neurogenesis in the
hippocampus. (Barlow & Durand, 2005) Patient going through ECT will be
administered with anaesthesia and muscle-relaxing drugs, this helps to prevent
bone breakage from the electric shock convulsions during the repeated seizures
given to the patient, which usually last for several minutes. There are few side
effects of ECT, which includes short term memory loss, confusion and case to
case some patients may have long-term memory problems. (OUM, 2011)
c) Transcranial Magnetic Stimulation (TMS) uses small electromagnetic coil with
the controlled of a computer program to send short bursts of powerful magnetic
energy, which is focused to the brain’s frontal cortex. This procedure is
non-evasive, requires no anaesthetic or sedation. The TMS procedures do not
directly affect the whole brain, the aimed is to only reach about 2 to 3 cm into the
brain directly underneath the treatment coil. These electrical currents activate
cells within the brain, which are thought to release neurotransmitters. TMS

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procedures is recommended for major depression disorder in adult patients, who
have failed to respond from anti-depressant medications. From research collected
there is a significant improvement in depression symptoms on patients treated
with TMS. (OUM, 2011)
d) Psychosurgery is considered one of the most controversial treatment for
psychological disorders, and this choice of treatment would be a last resort for
patients who have had fail to respond to all other forms of clinical intervention.
In this procedure a precise surgical ablation is made in the brain tissue, in another
word a brain surgery done to alter the patient cognitive states, that is caused by
mental disorder. (Ciprani, Barbui, Salanti &2011)
2) Psychosocial Intervention
In psychosocial intervention, we can look at these treatments here, which are
psychotherapy, psychoeducational, social skills training and group support. All of
which these psychosocial intervention treatments are to treat the imbalance
chemical in the brain, let’s look at each of these treatment in depth.
a) Psychotherapy, also known as ‘Talk Therapy’ where for this treatment it involves
‘face-to-face’ sessions with a psychotherapist. There are several approach to
psychotherapy which are as follows: (Cipriani, Barbui & Salanti, 2011)
Psychoanalysis, Behavioral Therapy, Person-Centered Therapy, Gestalt Therapy,
Cognitive Behavioral Therapy and Existential Therapy.
b) Psychoeducation, this refers to a specific process of educating both the patients
and their family on assessing facts about the illness in a concise manner. This
method is part of a treatment plan, as it promote patient on coping strategies in
dealing with the issues and how their family member can help to care and gives
support. (OUM, 2011)
c) Social Skills Training, also known as SST is a method helps people to learn a
socially appropriate behaviour and how to interact with to improve their ability to
function in everyday social situations. SST technique has been found to be
effective in the treatment of patients with a wide range of emotional problems.

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Where in the case of schizophrenic patients SST prove to help in making better
eye contact with others and overall conversational skills. (OUM, 2011)

Proposal of treatment plan for bipolar disorder (using biological intervention)

From recent studies on the developments in the acute and long-term treatment of bipolar
disorder, it has been seen that advances in psychopharmacotherapy or drug treatment
remain as quite a modest choice. Antipsychotic drugs are effective in the acute treatment
of mania, in bipolar disorder patients. Treatment of bipolar disorder conventionally
focuses on acute stabilisation, in which the goal is to bring a patient with mania or
depression to a symptomatic recovery with stable mood, in which the goals are relapse
prevention, reduction of subthreshold symptoms, and enhanced social and occupational
functioning. Treatment of both phases of the illness can be complex, because the same
treatments that alleviate depression can cause mania, and hypomania, hence the
treatments may reduce mania might cause rebound depressive episodes. (Zarate,
Brutsche, Ibrahim, & et al, 2011)
Most newly introduced treatments for bipolar disorder, in pharmacological have been
based on an extension use from another disorder such as antipsychotics in mania and
antidepressants for bipolar depression. However, lithium remains unique because its main
therapeutic use is in bipolar disorder, and investigation of its mechanism of action has,
and remains, crucially important in the identification of future targets. (Ciprani, Barbui,
Salanti &2011)
In studies conducted, shows a pioneering trials of lithium and chlorpromazine were done
in the 1970s and were followed by a focus on antiepileptics example valproate and
carbamazepine, in the 1980s and 1990s. Few trials directly assessing the comparative
efficacy of different second-generation antipsychotics exist, but a mixed treatments
meta-analysis compared 13 agents studied in 68 randomised controlled trials. This
review found substantial and clinically important differences in terms of both efficacy
and tolerability between agents. Antipsychotic drugs seem to be better than
anticonvulsants and lithium in the treatment of manic episodes. Olanzapine, risperidone,
and haloperidol seem to have the best profile of presently available agents. Therefore,

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antipsychotic agents will often be the appropriate short-term clinical treatment, although
a drug with better long-term evidence of efficacy such as lithium might be preferred
when continued drug therapy is planned.
The treatment of bipolar depression is a major challenge, with few treatments of proven
efficacy and, in particular, substantial controversy about the role of antidepressant drugs.
Following the work of Emil Kraepelin, in a typical antipsychotics have been investigated
in bipolar depression with variable results. Treatment with quetiapine leads to more
symptomatic improvement in patients with bipolar depression than do placebo,
paroxetine, and lithium. Some evidence exists of a reduced risk of recurrence in patients
who respond to acute-phase treatment and continue quetiapine rather than switch to
placebo. Thus, continuation could be of benefit in patients who can tolerate the drug’s
adverse effects, including sedation and weight gain. The reasonably fast onset of action
of quetiapine is clinically useful because it provides clinicians and patients with a
treatment that can be initiated early in the course of a worsening depression in the same
way that antipsychotics are used for emerging manic symptoms. Combined olanzapine
and fluoxetine leads to more symptomatic improvement than does olanzapine or placebo
alone, which could suggest that fluoxetine is an effective treatment of acute bipolar
depression or that the combination of fluoxetine and olanzapine is synergistic. (Judd,
Akiskal & Schettler, 2002)
So far, the investigation of a typical antipsychotic drugs has been instructive for both
clinical and methodological reasons. Quetiapine and olanzapine–fluoxetine combination
have regulatory approval for bipolar depression in some countries and are included as
first-line recommendations in recent guidelines. Emerging evidence suggests that
lurasidone might also be efficacious, whereas aripiprazole does not seem to be so. The
transdiagnostic benefits of a drug like quetiapine, which is antipsychotic, antimanic, and
antidepressant in bipolar depression, emphasises the importance of the investigation of
treatment effects. However, this non-specificity and scarcity of convincing evidence of
long term effect of modification by known mechanisms suggests that the effects are
mediated by short term easing of the symptoms. Nonetheless, because bipolar disorder is
very difficult to treat, this relief is often useful for patients. Further, combinations of a

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typical antipsychotics with selective serotonin-reuptake inhibitors, or with agents that
have medium-range term to long term effects on depression are often used in clinical
practice and in need of justification for further investigation in clinical trials. (Harwood,
2005)

Justification of proposed treatment plan.

A research report done in an eight-week, open-label, prospective study of olanzapine
monotherapy involving 23 bipolar youths with manic, mixed, or hypomanic, shows an
effectiveness in the treatment of acute mania in both children and adolescents. Weekly
assessments were further made using the Young Mania Rating Scale (YMRS), Clinical
Global Impressions Severity Scale (CGI-S), Brief Psychiatric Rating Scale, and
Children’s Depression Rating Scale, to obtain solid evidence on an adverse events were
assessed through self-reports, vital sign and weight monitoring, laboratory analytes, and
extrapyramidal symptom rating scales. (Goodwin, 2009)
From this the results showed that, 22 of the 23 youths completed the study. Endorsing
that Olanzapine treatment was associated with significant improvement in mean YMRS
score. Using predefined criteria for improvement of more that 30% decline in the YMRS
and a CGI-S Mania score of more than 3 at endpoint, the overall response rate was 61%.
Overall, olanzapine was well tolerated, and extrapyramidal symptom measures were not
significantly different from baseline. Body weight increased significantly over the study.
In conclusions, the open-label olanzapine treatment was efficacious and well tolerated in
the treatment of acute mania in youths with bipolar disorder. Further finding stated that
the efficacy with future placebo-controlled, double-blind studies are warranted.
(Goodwin, 2009)
Lithium, introduced by John Cade in 1949, remains the best established long-term
treatment for bipolar disorder. Although the metal has been in clinical use for more than
50 years, the most convincing evidence of long-term efficacy comes from randomised
clinical trials in which lithium was included as an active comparator. A meta-analysis of
five placebo-controlled lithium maintenance trials showed that lithium reduces the risk of
manic relapses by 38% and depressive relapse by 28%. Lithium is the only known
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anti-suicidal treatment with randomised evidence of a reduction in the risk of suicide of
more than 50%. (Strockmeier, 2003). However, the benefits of lithium are restricted by
adverse effects and a low therapeutic index. Although little evidence exists of a clinically
substantial reduction in renal function in most patients, the risk of end-stage renal failure
remains unclear. The risk of congenital malformations in the babies of mothers who have
taken lithium during pregnancy is uncertain, but probably lower than previously thought.
The balance of risks should be considered before lithium is withdrawn during pregnancy.
In addition to known effects of lithium on the thyroid, the risk of hyperparathyroidism is
increased and calcium concentrations should be checked before and during treatment.
(Gitlin, Swendsen, Heller & Hammen, 1995)
The limitations of lithium mean that alternatives are often needed for long-term
treatment. A pooled analysis of two randomised lamotrigine versus placebo trials
reported a 36% reduction for lamotrigine in the risk of relapse over 18 months. Despite
the dramatic increase in the use of valproate in the past two decades, placebo-controlled
evidence for valproate in long-term prevention remains scarce. Moreover, the trial found
that lithium was better than valproate in the prevention of mood episodes, but with a
combined analysis finds heterogeneity between studies. Combination treatment with
lithium plus valproate is better than treatment with valproate monotherapy. (Judd,
Akiskal & Schettler, 2002)
Enrichment designs are standard in continuation trials sponsored by industry. Enrichment
selects patients with known acute response to, or who can tolerate, the investigational
agent. Patients are then randomly assigned to either continue the investigational agent
during the active trial or switch to placebo or an active comparator. The enrichment
design can answer questions about the continued benefits of the investigational medicine,
but is not a fair test of the comparator agents that do not have the prerandomisation
selection. For example, one trial protocol treated 2438 patients with quetiapine for 4 to
24 weeks, and of which 1226 (50%) who responded to treatment were randomly allocated
to continue quetiapine or to switch to placebo or lithium. Over 104 weeks,
time-to-recurrence of any mood event was significantly longer for patients given

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quetiapine versus placebo and for patients given lithium versus placebo. (Cousins, Butts
& Young, 2009)
Because antipsychotics are the most potent treatments in acute mania, in many clinical
situations, it will seem reasonable to continue them after remission from the acute
episode. However, there are few long-term trials, most use enrichment designs, and none
have the same degree of independent replication of efficacy as lithium. Thus, the role of
antipsychotics as long-term mood stabilisers remains uncertain. (Ciprani, Barbui, Salanti
&2011)
Discussion on how psychosocial intervention might be a better or worst option to
treat bipolar disorders.
Despite their widespread use, considerable uncertainty and controversy remains about the
use of antidepressant drugs in the management of depressive episodes. Lithium has the
strongest evidence for long-term relapse prevention; the evidence for anticonvulsants
such as divalproex and lamotrigine is less robust and there is much uncertainty about the
longer term benefits of antipsychotics. Substantial progress has been made in the
development and assessment of adjunctive psychosocial interventions. Long-term
maintenance and possibly acute stabilisation of depression can be enhanced by the
combination of psychosocial treatments with drugs. The development of future
treatments should consider both the neurobiological and psychosocial mechanisms
underlying the disorder. Clarification of the mechanisms by which different treatments
affect sleep and circadian rhythms and their relation with daily mood fluctuations is likely
to help with the treatment selection for individual patients. (Cipriani, Barbui & Salanti,
2011)
Most studies of psychotherapy for bipolar disorder are maintenance trials in which
patients receive standard drugs and either an experimental psychosocial intervention or
usual care as such, a brief treatment or a supportive treatment of equal frequency for a
certain duration. A meta-analysis of eight maintenance psychotherapy trials, which
included family, individual, and group treatment trials, yielded to some good ratio
success for reductions in any type of mood relapse to for enhanced social functioning.
(Merikangas, Akiskal, Angst & et al, 2007)

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A study compared up to 30 sessions of family-focused therapy, interpersonal and social
rhythm therapy, or cognitive-behavioural therapy such as intensive treatment, with a brief
psychoeducational therapy for 293 patients with acute depression who also received
mood stabilisers. In this study in over a year, the patients in intensive therapy recovered
more rapidly and were more likely to be clinically well in any study month than those in
brief treatment. Effects extended to relationship functioning and life satisfaction. No
differences emerged between the three intensive modalities in symptoms or psychosocial
functioning over 1 year. Interestingly, patients with depression in this research who were
treated with mood stabilisers and randomly assigned to adjunctive anti-depressant
treatment did not recover faster than patients who were assigned to adjunctive placebo
treatment. Therefore, psychosocial treatment might be a more effective adjunct to mood
stabilisers than antidepressants after a bipolar depressive episode. (Zarate, Brutsche,
Ibrahim, & et al, 2011)
A Canadian trial compared six group psychoeducation sessions with 20 sessions of both
types of interventions, cognitive-behavioural therapy, and pharmacotherapy. The studies
on the 204 patients in full or partial remission. Evidence showed that no differences were
recorded over a 72 weeks of sessions, in symptom burden or recurrence. In summary, the
evidence for adjunctive cognitive-behavioural therapy for relapse prevention is
inconclusive. (Strockmeier, 2003)
Advances in the pharmacological treatment of bipolar disorder have come mainly from
the repurposing of drugs used in other neuropsychiatric disorders, and do not target the
mood instability that characterises the disorder. Dopamine antagonism seems to be a
potential target for antimanic treatments, but the scarce convincing evidence that
increasing serotonergic transmission improves symptoms in bipolar depression shows the
need for development of bipolar-specific validated targets for novel treatments. (Cipriani,
Barbui & Salanti, 2011)
Opportunities should increase with the implementation of new methods such as the use of
induced pluripotential stem cells to provide in-vitro models of neural systems, the
identification of genetic and epigenetic factors, and the use of optogenetics to develop
more precise animal models. Meanwhile, faced with the neurobiological complexity of

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the disorder, present approaches to drug discovery and repurposing will need to use
existing targets in addition to any novel targets such as oxidative damage. (Michalak,
Livingston, & Haddock, 2011)

Conclusion
Drug and psychotherapy trials have largely proceeded independently of one another.
Specifically, drug studies have not examined the effects of psychotropic agents on
psychosocial variables such as when a patient’s ability to regulate emotions in response to
life events), nor have psychotherapy studies analysed changes in presumed biological
mechanisms that is to a certain degree of amygdala activation in emotional challenge
paradigms. Pragmatic trials that examine the interactive effects of psychotropic drugs
and psychotherapy in maintenance treatment would help to move the field forward. For
example, a trial in which patients with bipolar disorder in the depressive phase of illness
are initially treated with quetiapine or lithium or both, and then randomly assigned to
continued pharmacotherapy with adjunctive psychotherapy versus adjunctive
antidepressants, could help to define effective algorithms for bipolar depression. (Zarate,
Brutsche, Ibrahim, & et al, 2011)
Innovations in service provision often focus on the early detection of manic and
depressive symptoms. In our opinion, early detection combined with helpful
self-management and targeted psychosocial and drug treatment promises substantial
benefits. (Strockmeier, 2003)
Treatment guidelines increasingly suggest that optimum management of bipolar disorder
needs integration of pharmacotherapy with targeted psychotherapy. A recent randomised
trial in Denmark has shown clinical benefits from this approach. Psychological
approaches build on evidence that psychosocial stressors, including excessive family

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discord or distress, negative life events, or events that disrupt sleep and wake rhythms or
accelerate goal attainment are associated with relapses and worsening symptomatic
states. The main goals of adjunctive psychotherapy for bipolar disorder include the
education of patients, and when possible, caregivers, about strategies for the management
of stress, the identification and intervention of early signs of recurrence, and how to keep
regular lifestyle examples such as sleep and exercise habits. Moreover, in view of the
high rate of non-adherence to drug treatments, psychosocial treatments emphasise
consistency with pharmacotherapy. (Cipriani, Barbui & Salanti, 2011)

References
1. Dilsaver, S.C, 2011. An estimate of the minimum economic burden of bipolar I
and II disorders in the United States. (129:79–83)
2. Cipriani, A, Barbui, C, Salanti, G, 2011. Comparative efficacy and acceptability
of antimanic drugs in acute mania: a multiple-treatments meta-analysis.
3. Cousins, D.A, Butts, K, Young, A.H, 2009. The role of dopamine in bipolar
disorder. Bipolar Disord.
4. Gitlin, M.J, Swendsen J, Heller TL, Hammen C, 1995. Relapse and impairment
in bipolar disorder. Am J Psychiatry. (152:1635–40)
5. Goodwin, G.M, 2004. Antidepressants for bipolar depression: a systematic review
of randomised controlled trials. (61:1537–47)
6. Harwood, A.J, 2005. Lithium and bipolar mood disorder: the inositol-depletion
hypothesis revisited. Mol Psychiatry.
7. Judd, L.L, Akiskal, H.S, Schettler, P.J, et al. 2002. The long-term natural history
of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry.
8. Merikangas, K.R, Akiskal, H.S, Angst, J, et al. 2007. Lifetime and 12-month
prevalence of bipolar spectrum disorder in the National Comorbidity Survey
replication. Arch Gen Psychiatry (64:543–52).
9. Michalak, E, Livingston, J.D, Haddock, C, 2011. ‘It’s something that I manage
but it is not who I am’: reflections on internalized stigma in individuals with
bipolar disorder.

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10. OUM, Aug 2011. First Edition. Clinical Psychology.
11. Stockmeier, C., 2003. Involvement of serotonin in depression: evidence from
postmortem and imaging studies of serotonin receptors and the serotonin
transporter. J Psychiatric Res.
12. Zarate, C.A, Jr, Brutsche, N.E, Ibrahim, L, et al. 2011. Replication of ketamine’s
antidepressant efficacy in bipolar depression: a randomized controlled add-on
trial. Biol Psychiatry; (71:939–46)

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