PSY 100Y5

TREATMENT OF DISORDERS LECTURE
DR. KIRK R. BLANKSTEIN
OUTLI NE
¯ 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
social skills
symptoms of
psychopathology
(diagnosis)
Biological
factors
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
personality
cognitive style
social skills
symptoms of
psychopathology
(diagnosis)
Biological
factors
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.
Levels of Analysis in
ASSESSMENT
¯ Clinical psychologists typically employ three primary modes
of assessment:
¯I NTERVI EWS: gather information
from the person’s point of view.
gTESTS: can be “objective” or
“projective.
@DI RECT OBSERVATI ON: 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)
g 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)




CRI TI CAL
THI NKI NG
• 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
getting help
from a friend
rather than a
therapist
¯ COST
g LESS STIGMA
@CONVENIENCE
j INTIMATE
KNOWLEDGE
_ Advantages of
getting help from
a therapist rather
than from a
friend
¯ EXPERT OPINION
g KNOWLEDGE OF
RESOURCES
@UNDERSTANDING OF
SERIOUS PROBLEMS
j CONFIDENTIALITY
) OBJECTIVITY
g SEPARATION FROM
PERSONAL LIFE
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.
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
Psychodynamic
Psychotherapy

MANY VARIATIONS OF THIS
SHORT-TERM INSIGHT-
ORIENTED TREATMENT;
THERAPIST IS MORE
DIRECTIVE OR
CONFRONTATIONAL IN
INTERPRETING DEFENSES;
TREATMENT FOCUSES ON
SINGLE ISSUE OR THEME
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.
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

Criteria for a Panic Attack
TYPES
1) Cued or Situationally Bound
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
Psychological Factors
Social/Environmental
Factors
• genetics
• neurobiology
(BIS, FFS)
• sense of controllability
• conditioning
• cognitions/expectancies of
danger
• anxiety sensitivity
• stressful life
events
• social
pressures to
succeed
Differential Diagnosis
Anxiety
Disorder
GAD
Panic
Disorder
Specific
Phobia

Social
Phobia

PTSD

OCD
Focus of the Anxiety
¬ minor everyday events
¬ the next panic attack

¬ specific situations/objects

¬ embarrassment/evaluation in
social situations

¬ avoidance of thoughts/images of
past trauma
¬ 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
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. Modeling
5. Interoceptive Exposure
6. Breathing Retraining
7. Deep Muscle Relaxation
8. Cognitive Therapy (Restructuring)
– probability overestimation, catastrophic
cognitions, self-talk
Overview: Cognitive-Behavioral
Treatment Strategies
9. Social Skills/Assertiveness Training
10. Coping Skills
11. Problem Solving
12. Homework
– handouts, tapes, self monitoring
13. Pharmacotherapy
– SSRI’s, high potency benzodiazepines,
TCA’s


**Variation: individual vs. group
Overview: Cognitive-Behavioral
Treatment Strategies -- continued
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)
• 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
Principles of Effective
Exposure
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
My boyfriend He’s losing interest
didn’t call on in me.
Friday. He’ll leave me.














I feel rejected.
It means I’m
undesirable. No
one will ever love
me. I’ll always be
alone.
RATIONAL REPLIES


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.


(Ask the same kinds of
questions as those listed
above, and try to come up
with more realistic
thoughts.)
MEICHENBAUM’S
CONSTRUCTIVIST COGNITIVE-
BEHAVIORAL 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.



± 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.
Ò TASK: Using this framework, evaluate the therapies studied in this course to determine
which have these elements in common.
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
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
• Genetic factors
• Physical trauma
prenatally or
during birth

• Structural
abnormalities of
the brain
• Abnormalities in
neurotransmitter
systems
• Psychosis-prone
personality
STRESSORS
• 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
g 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
EMOTI ON” 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 EMOTI ON usually involves high levels of
¯criticism (“You don”t do anything but sit in front of the TV”
ghostility (“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
ESTABLI SHED I N THE OLD YORK (TORONTO)
J AI L, I N J ANUARY, 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
OThe 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)
O 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
g 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
j 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.
O 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.
By Scott Simmie,
The Toronto Star, October 10, 1998
¯ MONEY
¯ HOUSING
¯ COMMUNITY
MENTAL HEALTH
CENTRES
¯ PROVINCIAL
PSYCHIATRIC
HOSPITALS
¯ RISK ASSESSMENT
¯ DIVERSION
PROGRAMS
¯ COMMUNITY
TREATMENT ORDERS
¯ “BEST” DRUGS FIRST
¯ KIDS--A CLEAR
PRIORITY
¯ CRISIS CENTRES--A
PLACE TO GO
¯ CRISIS LINES--A
PLACE TO CALL
¯ ALTERNATIVE
BUSINESSES
¯ INCOME SUPPORTS
¯ DRUG COVERAGE
EXTENSION
¯ THE DOCTORS
¯ ANTI-STIGMA
CAMPAIGN
¯ THE AGENCIES
¯ EMPLOYERS
¯ CONSUMERS
¯ THE POLICE
¯ THE MEDIA
¯ BUILDING A SYSTEM
¯ THE PUBLIC