Experience schizophrenia clip

THERAPIES

Biological & Psychological Therapies

for schizophrenia

AQA A Spec

“Biological therapies for schizophrenia, including their evaluation in terms of appropriateness and effectiveness”

A02 Evaluation …

•Appropriateness and effectiveness of therapies will be marked in exam questions

Exam tip !!

Appropriateness- ethical issues

Effectiveness - does it work

A02 Evaluation

1st ….

Biological Therapies for Schizophrenia

Need to learn 2 out of following 3

1. ECT 2. Psychosurgery 3. Drugs

‘Ice pick’ Historical treatment

Group Activity- PICTURES ONLYpresentation

1. ECT + appropriateness/effectiveness2. Psychosurgery + approp /effectiveness3. Drugs + appropriateness/effectiveness4. ??????

Info.

Brief HISTORY of therapies

Pre-1950’s• labotomies / straight-jackets used to ‘contain’

patients• ECT was used

But then …

Following the discovery of Dopamine in 1952

1.Drugs were developed that had a direct effect on the action of this neurotransmitter ..2.ECT was still used3.Use of Labotomies dropped

1. ECT

Electroconvulsive Therapy (ECT.)

• is a controversial psychiatric treatment, where an electric shock of about 100-150 volts is given to the brain usually in the course of 6-12 treatments administered 2 or 3 times a week.

Electroconvulsive Therapy (ECT.)

• This therapy works by using an electrical shock to cause a seizure (a short period of irregular brain activity) and it is believed that the seizure has a calming effect on the individual and reduces some of the anxiety associated with their symptoms.

Electroconvulsive Therapy (ECT.)

• Before each treatment, an intravenous line is attached and through it the patient will be given an anesthetic (to induce sleep) and a muscle relaxant.

• Then an electrical shock is applied to the patient’s head (via electrodes). The shock will last only 1 or 2 seconds (high voltage / low amperage) and will make the brain have a seizure.

Electroconvulsive Therapy (ECT.)

• This seizure is controlled by the medicines to stop/reduce the body having a grand muscular spasm.

• The somewhat dazed patient will then wake up within 5 to 10 minutes after the treatment.

Electroconvulsive Therapy (ECT.)

ECT Clip Longer• Clip update

How effective is this treatment?

• Electroconvulsive therapy is not considered a first line treatment for schizophrenia but may be prescribed as a fast and short-term improvement of severe symptoms after all other treatment options have failed or when the situation is thought to be life threatening.

How effective is this treatment?

• Under NICE guidelines it can be recommended if it has been previously effective and the symptoms of catatonia are present. There is no recommendation for the use for schizophrenia otherwise

How appropriate is this treatment?

• Like with all treatments a risk-benefit assessment for the individual should be made and documented which outlines the possible adverse effects of ECT and the risks of not having treatment.

• Form an ethical point of view the doctor should keep strictly to recognised guidelines about consent and should not be put any pressure on the person to give their consent.

How appropriate is this treatment?

• Even if the patient is sectioned under the Mental Health Act, if they are mentally capable of making a decision about their treatment they should decide, after discussion with the doctor whether or not they want to give their consent to have ECT.

How appropriate is this treatment?

• They should always be reminded that they have the right to change their mind either for or against the treatment at any time. The patients should be re-assessed after every session of ECT.

• The treatment should be stopped as soon as the patient has responded if there are adverse effects or if they withdraw their consent.

How appropriate is this treatment?

• Finally the main concern with ECT is that it has been shown to cause persistent long-term memory loss and short-term confusion. However it is a fast and cost-effective short-term solution for some forms of schizophrenia.

EVALUATION(Effectiveness)

Advantages This seizure releases a ‘rush’ of chemical neurotransmitters and alters function (e.g. perception/memory etc)•ECT can have an immediate beneficial effect (Schap 1998) •Significant benefit of ECT over placebo (Bloot 2001)•Huge research shows no damage to brain after ECT (Gross 2009)

Electroconvulsive Therapy (ECT.)

Effectiveness •It is only measurably effective where symptoms of catatonia are present and in terms of treatment for drug-resistant catatonic schizophrenia•The change in chemical neurotransmitters and altered function (e.g. perception/memory etc) is only a temporary one as such treatments have to be repeated.

Electroconvulsive Therapy (ECT.)

Appropriateness- Disadvantages

•Common side effects include temporary short-term memory loss, confusion, paranoia, nausea, muscle aches and headache. •Some people may have longer-lasting/permanent problems with memory/paranoia.

Electroconvulsive Therapy (ECT.)

Appropriateness + effectiveness

•Nowadays, rare cases result in death. (In the past it was often caused by poor calibration of the shock, coupled with a lack of muscle relaxants) •Risk of cognitive impairment•Unscientific•Risk of becoming used for social control?

2. PSYCHOSURGERY

Pre-Frontal Lobotomies

Historical Treatment New Treatment

“A surgical operation involving incision into the prefrontal lobe of the brain, formerly used to treat mental illness.”

lo·bot·o·my  

Psychosurgery:-

• Psychosurgery is a surgical procedure for treating mentally disordered behaviour. By removing or destroying part of the brain, the aim is to eradicate the undesirable behaviour.

Psychosurgery:-

• Psychosurgery is a treatment of last resort, used only in extreme cases when other treatment methods have failed and where, because of the disorder, the person is likely to cause harm to themselves or others.

History of Psychosurgery

• The first use of psychosurgery to treat schizophrenia came in the 1930’s with attempts to sever the connections between the frontal lobes and the rest of the brain. The first human leucotomy (a leucotomy refers to what is now more commonly known as a prefrontal lobotomy.) was performed by Antonio Egas Moniz in 1936. He won the Nobel Prize for medicine in 1949 for this work.

Psychosurgery:-

• The patients treated were calmer and displayed none of the symptoms of the disorder of schizophrenia: however, they were sluggish and apathetic and had no real quality of life.

Psychosurgery:-

Psychosurgery:-

• Eventually he began performing this procedure on anyone who wished to have one. The exact figure is not known, but it is estimated that some 18,000 lobotomies were performed in the USA alone between 1939 and 1951.

• By the 1970s, the use of frontal lobe lobotomies had all but died out due to the introduction of drug therapies.

Psychosurgery:-

Clip- 5 mins

Up-to-date modernPsychosurgery

Related terminology more modern techniques.•Lobotomy: the severing of the connection between the frontal cortex and the lower parts of the brain.Prefrontal lobotomy: drilling two holes in the skull and inserting an instrument that severs nerves in the brain.

Psychosurgery:-

• Cingulotomy: an incision is made in the nerves of the brain and a MRI (Magnetic Resonance Imaging) scan aids the guidance of surgical instruments.

Evaluation (effectiveness)

Advantages•Reduces the risk of suicide in severe depression from 15 percent to one percent (Verkaik, 1995). Depression could be a side effect/consequence of schizophrenia.

•Studies using MRI have shown that there is abnormal functioning in the frontal lobes of schizophrenics. Therefore the treatment is supported by modern science.

Advantages

•A surgery that reduces the functioning of the frontal lobe may actually help to control the symptoms of some sufferers. Is deliberately damaging the brain can ever be justified?•Between 1942 and 1954, 41% of patients who underwent such procedures ‘recovered’ or “greatly improved”, 28% were “minimally improved”, 25% showed “no change”, 4% had died, and 2% were made worse. (Tooth & Newton, 1961).

Evaluation (effectiveness)

Effectiveness• Disadvantages-• Some psychologists have taken issue with

findings of Tooth & Newton (1961) these issues generally surround the definition of the term ‘recovered’. This term is wholly inappropriate when discussing the effects of psychosurgery on sufferers of schizophrenia.

Appropriateness

• Disadvantages

• But Psychosurgery produces inconsistent outcomes. Behaviour change occurs in some individuals and not in others, so it is difficult to predict who will be affected and how .

• The main ethical problem with psychosurgery is that the procedures are irreversible because neural tissue has been destroyed i.e. it cannot be undone, meaning the side effects are permanent.

Appropriateness

Disadvantages

•Comer (2002) found that Lobotomies had a fatality rate of 6% and a range of severe side effects such as brain seizures and a lack of emotional responsiveness.

Appropriateness

• Disadvantages

• Major loss of memory, emotional disturbance, loss of creativity, personality change, lack of social inhibition and other serious problems have been noted as side effects of psychosurgery.

Effectiveness

• Psychosurgery reduces the symptoms in the same way that drinking alcohol ‘cures’ anxiety and stress....

• NB: As recently as the 1990s, Psychosurgery was reported to be beneficial in some cases of severe anxiety, depression and obsessive-compulsive disorders (Beck and Cowley, 1990).

3. Drug Therapy

Dopamine Hypothesis

• Treatment is based on the dopamine hypothesis – the theory that schizophrenia is linked to increased dopamine activity in the brain. Antipsychotic drugs (neuroleptics) work by blocking dopamine receptors.

Drug Therapy

• Drug therapy is used in the treatment of schizophrenia to moderate or correct the neurochemical imbalances that produce psychosis.

• The most common atypical drugs used include perphenazine and clozapine.

How effective is this treatment?

• The most effective treatment is atypical antipsychotic medication, which reduce the positive symptoms of psychosis in a relatively short space of time around 7-14 days.

• In 2008 results from a major randomised trail sponsored by the US National Institute of Mental Health (Clinical Antipsychotic Trials of Intervention Effectiveness or CATIE) found that a perphenazine was as good as the newer drugs and more cost-effective when taken for up to 18 months.

How effective is this treatment?

• Such drugs have been used effectively as a first-line treatment for early-onset schizophrenia in children and teenagers.

• However the advantages of using these drugs come at the cost of an increased risk of metabolic syndrome and obesity which is of concern in the long-term use begun at an early age.

• Furthermore in 2006 USA Today published an article about the effects of antipsychotic medication in children.

How appropriate is this treatment?

• None of the atypical drugs had been approved for children and 2000 and 2004 there were 45 reported deaths in which an atypical antipsychotic was listed as the “primary suspect”. There were also 1328 reports of serious and sometimes life threatening, side effects.

• These include tardive dyskinesia (involuntary jerking and facial grimacing) and dystonia (involuntary muscle contractions that can interfere with talking and eating).

How effective is this treatment?

• Therefore it is clear that in the case of children and teenagers who have schizophrenia, medication should be used with extreme caution and only combination with individual therapy and family-based interventions.

How effective is this treatment?

• Response of symptoms to medication is variable: treatment-resistant schizophrenia is a term used for the failure of symptoms to respond satisfactorily to at least two different antipsychotics.

Appropriateness

• Patients in this category may be prescribed clozapine a medication of superior effectiveness but has several potential side effects.

• One of the main problems that is generally associated with drug therapy programmes are that patients become dependent and addicted to the drugs (Ross and Read 2004

• However in the case of schizophrenia, where there is currently no “cure” the side effects are a reasonable cost to offset against the serious and life threatening symptoms of schizophrenia.

Appropriateness

Side effects

Symptoms

Appropriateness

• This means that the treatment would have to be for a lifetime and will ultimately remove all responsibility and control from the patient raising ethical concerns.

• Such a permanent treatment is also very costly.

Drug Therapy

Effectiveness

•Drug therapy is effective at reducing positive symptoms e.g. hallucinations.

•It is successful for a large number of schizophrenia patients, meaning that more people can live in the community rather than being institutionalised.

Drug Therapy

Effectiveness

•It is the most widely- used and effective form of treatment for schizophrenia.

•Almost all other treatments are used alongside drug therapy.

Drug Therapy

• Effectiveness

• Drug therapy is not very effective for treating negative symptoms like social withdrawal.

Effectiveness

• It treats the symptoms of schizophrenia but not the cause.

• Symptoms often come back if people stop taking antipsychotic drugs.

• This leads to the ‘revolving door phenomenon’, where patients are constantly being discharged and re-admitted to hospital.

Appropriateness

• Disadvantages

P There are ethical issues surrounding the use of drug therapy.

E Some people argue that drug treatment is a ‘chemical straitjacket’

E It does not really help the patient, it just controls their behaviour to make it more socially acceptable and easier to manage.

Appropriateness

•Most people will experience some short term side effects when taking antipsychotic drugs e.g. drowsiness, blurred vision, dry mouth, constipation and weight gain.•Long-term side effects include increased risk of diabetes and tardive dyskinesia (involuntary repetitive movement that continue even after they have stopped taking the medication).

Effectiveness

• Clinical trials have shown that as many as two-thirds of people stop taking antipsychotic drugs because of the side-effects.

• However, newer antipsychotic drugs seem to have fewer long-term side effects than the older ones.

Thursday 25th April Essay question

Discuss the extent to which biological therapies can be used to treat Schizophrenia ( 10+ 14 marks)

appropriateness effectiveness

A01 Plan

Describe overall theory behind biological therapies - + difference between historical/current therapiesi.e. labotomies until 1950’s when drugs therapy discovered

Briefly describe 2 of following; ECT or Psychosurgery orDrug Therapy

A02/3 - EVALUATION

• Appropriateness• Effectiveness(strengths & weaknesses

of therapies)

• A03 terms• IDA -ethics -cost benefit analysis of therapy

• Use researchers names to support PEE points