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Major psychological disorders: treatment and overview

Treatment for schizophrenia: antipsychotic medication and psychosocial interventions

Until the 1960s, individuals with schizophrenia were placed in mental hospitals often with little
real treatment other than controlling them. With the advent of medications in the middle of the
past century, it became possible for individuals with schizophrenia to live within community and
home settings. Individuals with schizophrenia tend to show more positive mental health
behaviours when living in a community. In some cultures, some towns show it as their daily duty
to take care of these individuals. Today after, initial hospitalization to gain control over
symptoms, many individuals with schizophrenia return to their families. Some individuals with
schizophrenia become homeless and are at the mercy of their community.
There has been a shift from viewing schizophrenia as a disorder with inevitable deterioration to
one in which recovery is possible. Recovery includes having a career. Living with schizophrenia
depends on the resources of the individuals in terms of intelligence, coping techniques and
willingness to accept the advice of professionals.
Treatment for schizophrenia involves addressing the specific stage of the illness. One major focus
of treatment and research is how early intervention at each stage can reduce the severity of that
stage. There are studies currently underway that are seeking to identify reliable indicators as to
who will develop schizophrenia later in life.
The internet provides access to local and national groups that offer support for those with
schizophrenia as well as their caregivers. To help individuals with schizophrenia cope with the
community, several support procedures have been developed. These include antipsychotic
medications as well as educational procedures to help the individual with schizophrenia and
his/her family understand the course of the illness and the type of support available.
Antipsychotic medications
The treatment of schizophrenia changed drastically in 1954 with the discovery of chlorpromazine.
When effective, this drug reduces agitation, hostility, and aggression. It also reduced the positive
symptoms such as hallucinations and delusions and increased the time between hospitalizations
associated with schizophrenia. Negative symptoms and cognitive deficits were not changed by the
drugs.
One problem of this and other initial drugs was side effects such as tardive dyskinesia, which is a
movement disorder that results in involuntary movement of the lower face and at times the limbs.
These purposeless movements include sucking, smacking the lips, and making tongue
movements. These and other side effects are difficult to reverse once the medication is given over
some time. Weight gain is also seen in antipsychotic medications. New and different classes of
neuroleptic medications have been developed with different or fewer side effects. These newer
drugs tend to reduce the positive symptoms of schizophrenia such as hallucinations and delusions.
They also help the individual think more clearly and remain calmer. Not all medications work for
all individuals. There is also some suggestion that different ethnic groups respond differently to
neuroleptics, although it is less clear whether it is genetic factors or diet that influence these
differences.
Medications for schizophrenia have been referred to as first-generation or second-generation
antipsychotics. Second-generation antipsychotics are also known as atypical antipsychotics. First-
generation antipsychotics influence dopamine receptors although the exact mechanism by which
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they work is still being studied. One example of the first generation antipsychotic medication is
haloperidol, which has several trade names worldwide, one being Haldol. Second-generation or
atypical antipsychotic medications influence the dopamine receptors differently. Other first and
second-generation antipsychotics are successful in treating the positive symptoms seen in
schizophrenia. One advantage of second-generation antipsychotics is that they are also able to
treat negative symptoms. It was thought the second generation antipsychotics had fewer motor
side effects, but this has not always been the case.
Psychosocial interventions for schizophrenia
Psychosocial factors play an important role in the overall treatment of individuals with
schizophrenia. It has been estimated that over 60% of people with a first episode of major mental
illness return to live with their relatives. Families play an important role in supporting these
individuals. Family intervention for schizophrenia reduces relapse and hospitalization. Several
meta-analyses looked for evidence supporting family intervention. Family intervention includes
the following key components:
1. Provide practical emotional support to family members.
2. Provide information about schizophrenia, what mental health services are available in the
community, and nationwide support services.
3. Help the family develop a model of schizophrenia.
4. Modify beliefs about schizophrenia that are unhelpful or inaccurate.
5. Increase coping for all family members.
6. Enhance problem-solving skills.
7. Enhance positive communication.
8. Involve everyone in the relapse prevention plan.
The basic model suggests that what is important is how individuals interpret psychotic
phenomena. The overall model suggests that neurocognitive impairment in the premorbid state
makes the individual vulnerable to difficulties in school, and work which is less to non-functional
beliefs such as “I am inferior”, maladaptive cognitive appraisals, and in turn non-functional
behaviour such as social withdrawal. The cognitive approach is aimed at helping the client
understand the psychotic experience as well as cope with the experience and reduce distress. One
key feature of schizophrenia is the disruption of thought processes and a new part of the treatment
is directed at these illogical associations. Another focus of the treatment is directed at
interpersonal relationships and success at work. This approach may also involve skills training
such as self-monitoring and activity scheduling. Since individuals with schizophrenia may also
show mood and anxiety disorders, CBT aimed at these processes can also be utilized. The key
features of schizophrenia can be summarised as follows:
1. Develop a therapeutic alliance based on the client’s perspective.
2. Understand the client’s interpretation of aspects and present events.
3. Develop alternative explanations of schizophrenia symptoms.
4. Normalize and reduce the impact of positive and negative symptoms.
5. Educate the client in terms of the role of stress.
6. Teach the client about the cognitive model including the relationships between thoughts,
feelings, and behaviours.
7. Offer alternatives to the medical model to address medication adherence.

Developing a therapeutic alliance, which is a relationship between the therapist and client that
helps the work of therapy, it is an initial task of therapy. Part of this may include talking with the
client about his delusional beliefs.
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For example, if a client says that he invented a machine to solve the world’s problems, then the
therapist might ask when the person had this idea and what he has done to create the machine.
The therapist might also ask him about others who had helped him with these ideas. As with CBT
for other disorders, the basic idea is to look for inconsistent thoughts and conclusions that do not
follow logically.
Another major task of therapy is helping the individual develop an alternative understanding of
his/her symptoms. For example, some individuals with schizophrenia experience the voices that
they hear as coming from outside of them. One goal of therapy would be to help the client
reinterpret the source of the voices. Part of this may also include a cognitive assessment of
alternatives to being the voices.
The role of stress in increasing symptoms of schizophrenia is an important concept for clients to
understand. It is also important for them to understand the problems associated with not taking
medications to control the symptoms of schizophrenia. Keeping individuals with schizophrenia on
their medications is a difficult problem.
Expressed emotions refer to the emotions that the person with schizophrenia would experience
from others. That is, homes in which the person experienced critical comments, hostility, and
angry arguments were associated with relapse, whereas homes with warmth and positive remarks
were not.
A few approaches have been tried in the treatment of schizophrenia-early intervention. This
approach seeks out those who are high at risk for developing schizophrenia. The basic approach is
to help these individuals develop cognitive skills as a way to increase attention, memory,
executive control, and other cognitive process. Cognitive therapy is being used to reduce the
reactivity to stress seen in the period before the development of psychosis and to better
understand these individuals’ thoughts and feelings.
Another new approach, referred to as NAVIGATE has been designed for the treatment of first-
episode psychosis. NAVIGATE is a multidisciplinary team-based approach that emphasizes low-
dose antipsychotics medication, cognitive behavioural psychotherapy, family support and
education, and vocational and educational support. The program also helps the person to engage
in his/her community. One advantage of this approach is that the individual with the first episode
of psychosis receives all of these different treatment approaches.
Treatment of personality disorders
Although psychosocial treatment approaches come from different traditions, the effective
approaches show many common factors. BPD has been the focus of most empirical treatment
studies. The common factors seen in the treatment of BPD are:
1. A structured, manualized approach is used, which focuses on the commonly seen
problems.
2. Clients are encouraged to assume control of themselves.
3. The therapist helps the client to understand the connections of his/ her feelings to events
and actions. The therapist helps the client to consider the situation rather than just experience
anxiety.
4. Therapists are active, responsive, and validating.
5. Therapists are willing to discuss their reactions to the therapy session.
Dialectical behaviour therapy (DBT)
DBT therapy begins with the acceptance of the fact that individuals with BPD experience extreme
emotional reactions and are particularly sensitive to changes in the environment. Anger towards
the therapist is not uncommon. Individuals with BPD take a longer time to return to baseline
conditions after their emotional reactivity. They may be impulsive, suicidal considerations are
common. This makes these clients difficult to work with, and therapy sessions are often
challenging.
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The therapy is conceptualized in terms of several stages. The pre-treatment stage is a time when
the client and the therapist arrive at a mutually informed decision to work together. This includes
an understanding of the client’s history and decisions concerning which processes should receive
high priority. This pre-treatment stage also includes a discussion concerning what can be expected
from therapy and the roles of the therapist and the client. One emphasis is on the therapist and the
client as a team, whose goal is to help the client create a life worth living. In these services of
creating a productive life, individuals will develop problem-solving skills, for their own life.
The first stage of therapy is directed at helping the client develop a stable life. This includes
reducing suicide-related behaviors and other behaviours that interfere with therapy and life. This
stage typically lasts for 1 year. During this stage, dialectical thinking encourages clients to see
reality as complex and notwithstanding something that can be reduced to a single idea. This
includes developing the ability to experience thoughts and feelings that are experienced as
contradictory. This is a difficult task for those with BPD.
4 specific goals of stage 1 include suicidal ideation, reducing behaviours that interfere with
therapy, achieving a stable lifestyle, and developing skills in emotional regulation such as
mindfulness.
The second stage of therapy moves to processing previously experienced traumatic events. One
approach is to have the person re-experience prior trauma during the therapy sessions. This stage
can only occur once the person’s life is stable and the emotional response is under control. The 4
specific goals of this stage include remembering and accepting the intrusive material associated
with the earlier trauma as well as any denial associated with it, and resolving dialectical tensions
associated with blame for the trauma.
The third stage of therapy is directed at helping the person develop a sense of self that allows her
to live independently. The goal is to help the person experience both happiness and unhappiness
with the ability to trust in her experiences.
The fourth and final stage of therapy focuses on the ability to sustain joy and be part of an ever-
changing world.

Other proven therapies for treating borderline personality disorder

Dynamic deconstructive psychotherapy was developed for clients who find therapy difficult as
well as for those who may also have substance abuse problems. This approach is partly based on
neuroscience research, which shows that individual with BPD show difficulties with memories,
emotional regulation and decision-making. This is seen as preventing these individuals from
building a coherent self-system independent of other people.
DDP is divided into 4 distinct stages. The first stage is for the client and the therapist together to
identify the client’s difficulties and establish a series of goals and tasks for working on them.
They also create an agreement as to how the client will keep himself safe. By the end of this
stage, the relationship between the client and the therapist should be stable and give the client
comfort.
The second stage involves the development of the client’s ability to understand complex ideas
related to his relationship with others.
As his idealized image of himself and his abilities is given up, there can be a better understanding
of self-limitations, which is the focus of the third stage. During this stage, the client can learn to
verbalize and this can lead to disappointment and experience. The fears associated with them lead
to of personal incompetence. This can help the person understand these fears.
The fourth stage moves to the relationship between the client and the therapist and how the person
will experience the termination of therapy.
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Another empirically supported therapy is transference-focused therapy. This is a twice-weekly

psychotherapy based on Otto Kernberg’s objects relation model. As with their approaches TFP
seeks to reduce symptoms of BPD, especially self-destructive behaviours. The technique involves
an exploration of how the person views herself and may combine her identity with that of another.
She doesn’t have a stable view of self. During the first year of treatment, behaviours involved
with self-harm are limited, and a therapy contract is developed. In the sessions, the therapist
follows the effect that the client brings to the sessions. The emphasis is on the relationship
between the client and the therapist.

Treatments for other personality disorders

The individuals with other personality disorders about whom we have information present
problems with themselves and in their behaviour toward or relationships with others in several
different ways. This requires mental health professionals to pay attention to the specific way in
which an individual is interacting with his/her world. A general approach is taken in therapy.
The fundamental aspect of this general approach for all disorders is to focus on the relationship
between the mental health professional and the individual. This approach includes 6 general
components, 4 related to the relationship, and 2 related to assessing the individual in developing
certain skills.

1. Structure
Specify the model of treatment, describe the framework of therapy, define the therapy and
establish a treatment outcome.

2. Treatment alliance
Establish and maintain a relationship between the therapist and the client.

3. Consistency
Maintain a consistent treatment process.

4. Validation
Acknowledge the reality of the experiences of the client. This does not require that the therapist
agrees with the client’s explanation but only acknowledges that the experience has taken place.

5. Motivation
Help the client develop motivation and commitment

6. Metacognition
Promote the client's ability to observe and reflect on his/her behaviours and experiences.

As a part of the treatment perspective, it is important to help the client feel safe and contain
his/her experiences. From this perspective, there is more focus on aspects that can be changed
such as maladaptive thinking styles, attitudes about self and interpersonal patterns these more
integrated treatment approaches have been used with several personality disorder.
The type of personality disorder experienced determines the nature of the problems focused on in
treatment. Cluster A disorders of the schizotypal, schizoid and paranoid type show particular
problems in relation to their therapeutic relationship. The client may question the therapist’s
intentions, show aloofness and be very sensitive to what the therapist says. Clients with cluster B
personality disorders push the limits of the therapeutic relationship by being demanding or
seeking constant approval. Those being treated for cluster C disorders tend to be emotionally
imbibed and void of interpersonal conflict.
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The focus of treatment is often the prevention of future criminal or violent acts. In addition to
psychotherapy, medications have been used for specific aspects of different personality disorders,
such as depression or impulsivity. Unlike psychotherapy, there are no medications that target all
aspects of a personality disorder. Alternative therapies are in the process of being tested
empirically as to their effectiveness.

Neuro-cognitive disorders: prevention, treatment and support

Prevention of neurocognitive disorders
Cognitive challenges and social relations have been shown to help reduce cognitive decline. One
large-scale cognitive training program was directed at 2,832 individuals age 65 and older who lied
independently. These individuals received 10 training sessions for memory, reasoning, or speed of
processing. Cognitive measures and self-reported daily abilities showed beneficial effects of the
training, especially during the period 3-5 years after training. In comparison to control
individuals, who received training showed benefits after 10 years in reason and processing speed
but not memory. The results suggest that cognitive training can delay the onset of cognitive
decline.
Other prevention factors can be found through medical check-ups.
For example, blood pressure readings In childhood, midlife, and later life have shown that those
with higher blood pressure at an earlier age are at greater risk for neurocognitive disorders
through strokes.

Treatment and support for those with neurocognitive disorders

In the same way that cognitive training has been used to delay the negative effects of aging, it has
been used to help individuals with neurocognitive disorders recover cognitive functions that can
be restored, most of these training programs seek to help individuals maximize his strengths while
bypassing their weaknesses.
In addition to psychological approaches, medications are used for the treatment of neurocognitive
disorders. The neuro-cognitive disorders except for delirium cannot be cured. Sometimes the
symptoms can be reduced. There are also secondary symptoms such as anxiety and depression
that can be treated separately. At times, it’s difficult to distinguish depression from dementia. It
should be noted that with aging, medications can influence the body differently from how they
influence younger or middle-aged individuals. That is medication scans be absorbed and
distributed in the body differently. There can be more adverse side effects in older individuals.
Different medications are used for different neurocognitive disorders. In Alzheimer’s disease,
drugs such as cholinesterase inhibitors are used to increase memory and other cognitive
functioning by increasing concentrations of ACh in the hippocampus. Although useful, the
memory effects are modest. Since Parkinson’s disease is the result of dopamine neurons not
functioning correctly, treatment of Parkinson’s disease involves drugs that replace the most
dopamine such as L-dopa. However, it should be noted that dopamine replacement drugs are not
always effective. There are currently no medications directed at other neurocognitive disorders
such as frontotemporal neurocognitive disorder and Lewy body disease.
A different approach for Parkinson’s disease is deep brain stimulation, which was approved by
FDA in 2002. Deep brain stimulation for depression involves placing an electrode in the area of
the brain related to movement, usually the basal ganglia. This in turn is connected to a pulse
generator that is placed under the person’s skin usually near the collarbone. The pulse generator
can be programmed to stimulate the brain in several ways related to the individuals. Although not
all treatments that is recommended for all who have Parkinson’s disease, it have proven to
improve movement in a number of individuals.
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Overview of treatment: reasons to seek therapy, therapeutic relationship, combined treatments

and prevention intervention

Why people seek therapy?

People who seek therapy vary widely in their problems and their motivations to solve them.

1. Psychological disorders and stressful life circumstances.

Perhaps the most obvious candidates for psychological treatment are people experiencing one of
the psychological disorders that are described. About 15% of adults in the US receive mental
health care treatment each year with rates in other countries from 1-12%. Those with
psychological disorders, and those with serious conditions in which there is considerable
impairment in daily functioning are much more likely to receive treatment. Most people who
receive treatment do not meet the full criteria for psychological disorders. Many people seek
therapy due to sudden and highly stressful situations such as divorce or unemployment- situations
that can lead people to feel so overwhelmed by a crisis that they cannot manage on their own.

2. Reluctant clients
Some people enter therapy by an indirect route. Perhaps they were court-ordered to do so by the
judge because of substance abuse or domestic violence, or maybe they had consulted a physician
for their headaches or stomach pains, only to be told that nothing was physically wrong with
them. Motivation to enter treatment differs widely among psychotherapy clients. Reluctant clients
may come from many situations- a person with a substance abuse problem, whose spouse
threatens “either therapy or divorce” or a suspected felon whose attorney advises that things will
go better at trial if it is announced that the suspect has entered therapy. A substantial number of
angry parents bring their children to therapists with demands that their child’s problematic
behavior, which they view as independent of the family context be fixed. These parents may be
surprised and reluctant to recognize their own rules in shaping their child’s behaviour patterns.
Males are more reluctant to seek therapy or help when they are experiencing problems than are
females. In the case of depression, far more men than women say that they would never consider
seeing a therapist. When men are depressed they are even more reluctant to seek informal help
from their friends. When men do seek professional help, they tend to ask fewer questions than
women do.
Men are less able than women to recognize and label feelings of distress and to identify these
feelings as emotional problems. Men who subscribe to masculine stereotypes emphasizing self-
reliance and lack of emotionality also tend to experience more gender role conflict when they
consider traditional counselling, with its focus on emotion and emotional disclosure. For a man
who prides himself on being emotionally stoic, seeking help for a problem like depression may
present a major threat to his self-esteem. Seeking help also requires giving up some control and
may return counter to the ideology that “a real man helps himself”.
Men can be encouraged to seek treatment with the use of virtual reality therapy to treat soldiers
with post-traumatic disorder. Another strategy is to use more creative approaches to encourage
men to seek help and support. For example television commercials for erectile dysfunction use
professional basketball coaches to encourage men with similar problems to “step up to the plate”
and talk to their doctors. Making men more aware of those “masculine men” who have been man
enough to go for help when they needed it may be an important step toward educating those
whose adherence to masculine gender roles makes it difficult for them to acknowledge and seek
help for their problem.
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3. People who seek personal growth.

A final group of people who enter therapy have problems that would be considered relatively
normal. They appear to have achieved success, have financial stability, have generally accepting
and loving families, and have accomplished many of their life goals. They enter therapy not out of
personal despair or impossible interpersonal involvement but out of a sense that they have not
lived up to their expectations and realized their potential. These people, partly because their
problems are more manageable than the problems of others, may make sustainable gains in
personal growth.

Therapeutic relationship
The therapeutic relationship evolves out of what both, the client and therapist bring to their
therapeutic situation. The outcome of psychotherapy normally depends on whether the client and
the therapist are successful in achieving a productive working alliance. The client’s major
contribution is his/her motivation. Clients who are pessimistic about their chances of recovery or
who are ambivalent about dealing with their problems and symptoms respond less to treatment.
The key elements of the therapeutic alliance are:
1. A sense of working collaboratively on the problem.
2. Agreement between patient and therapist about the goals and tasks of therapy.
3. An affectionate bond between patient and therapist.
4. Clear communication is also important. This is no doubt facilitated by the degree if shared
experience in the background of the client and therapist.

Almost as important as motivation is a client’s expectations of receiving help. This expectancy is

often sufficient in itself to bring about sustainable improvement, perhaps because patients who
expect therapy to be effective engage more with the process. Just as a placebo often lessens pain
for someone who believes will do so, a person who expects to be helped by the therapist is more
likely to benefit. The downside of this fact is that if the therapy or therapist fails for whatever
reason to inspire the client’s confidence, the effectiveness of treatment is more likely to be
compromised.
To the art of therapy, a therapist brings a variety of professional skills and methods intended to
help people see themselves and their situations more objectively- provide a new insight, to gain a
different perspective. Besides helping provide a new perspective, most therapy situations also
offer a client a safe setting in which he or she Is encouraged to practice new ways of feeling and
acting, gradually developing both the courage and the ability to take responsibility or acting in
more effective and satisfying ways.

Combined treatments
The integration of mediation and psychotherapy remains common in clinical practice, particularly
for disorders such as schizophrenia and bipolar disorders. Such integrated approaches are also
appreciated and regarded as essential by the patients themselves. The integrative approach is a
good example of the biopsychological perspective that best describes current thinking about
mental disorders and that is reflected in the chapters.
Medications can be combined with a broad range of psychological approaches. In some cases,
they can help patients benefit more fully from psychotherapy.
For example- patients with social anxiety disorder who receive exposure therapy do much better
than if they are given an oral dose of D-cycloserine before each session. D-cycloserine is an
antibiotic used in the treatment of tuberculosis. When taken alone, it does not affect anxiety. D-
cycloserine activates a receptor that is critical in facilitating the extinction of anxiety. By making
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the receptor work better, the therapeutic benefits of exposure training are enhanced in people
taking D-cycloserine versus placebo.
Psychosocial interventions are combined with psychiatric medications. This may be especially
beneficial for patients with severe disorders. Keller and colleagues compared the outcome of 519
patients with depression who were treated with an antidepressant with psychotherapy or with a
combination of both of these treatments. In the medication-alone condition, 55% of the patients
did well. In the psychotherapy alone condition 52% of the patients did well. Patients for whom
the 2 treatments were combined did even better with an overall positive response rate of 85%.
Combined treatment is better because medications and psychotherapy may target different
symptoms and work at different rates. As Holon and Fawcett have noted, “pharmacotherapy
appears to provide rapid, reliable relief from acute distress, and psychotherapy appears to provide
broad and enduring change, with combined treatment retaining the specific benefits of each”.