PS3013 Clinical Psychology:Disorders of the brain or of the mind?

Dr. Andrew YoungBehavioural Neuroscience Research Group

amjy1@le.ac.uk

MSB Room 305

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Abnormal or Clinical Psychology?

Often used synonymously The study of behaviour outside the normal range Could define abnormal statistically

• But a behaviour may be quite common, yet still abnormal Therefore the concept of extreme rather than common

• But do not usually include all extremes

- Alturistic, truthful, happy

Need to consider

• Context, social dimension, appropriateness

• Is the behaviour disturbing to the patient and/or their social functioning or relationships?

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Criteria for ‘abnormal’ functionRosenhan & Seligman, 1995 Seligman et al., 2001

Factors in abnormal behaviour which bring it into clinical sphere

- Suffering, maladaptiveness

- Irrationality and incomprehensibility

- Unpredicatbility and loss of control

- Vividness and unconventionality

- Violation of moral and ideal standards

- Observer discomfort

• Borders difficult to define

• Criteria culturally dependent

• The more criteria met, the greater the abnormality

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Clinical Psychology, Psychiatry & Neurology I

Clinical Psychology

• Originally defined as psychological aspects of disorders treated in the disciplines of Neurology and Psychiatry

• Both disciplines were studying disorders of behaviour

Neurology

• Treatment of disorders of the brain

• Clear physical cause in the brain

Psychiatry

• Treatment of disorders of the mind

• No clear physical cause in the brainAMJY : Sept 2008

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Clinical Psychology, Psychiatry & Neurology II

Separation of illnesses of the mind from diseases of the brain

• Psychological & neurological treatments evolved separately

• Psychological (mind) treatments

- Psychotherapy, cognitive behavioural therapy

• Neurological (physical) treatments

- Direct physical evidence of brain involvement

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Origins of psychological treatments

Early treatments developed through the work of Freud

• Wanted a scientific theory of neurosis, with universal governing principles

• Trying to treat the symptoms and the underlying causes

• Believed that psychoanalysis was of limited applicabilityin psychosis (e.g. schizophrenia, depression)

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Psychiatric disorders : of mind or brain?

Psychiatric disorders

• Changes in mental phenomena infer illnesses of mind

• Possible that psychiatric disorders have origins in abnormalities in the brain

Neurological disorders

• Do also lead to mental and behavioural changes

• Changes similar to those in psychiatric patients can be caused by physical means

- Syphilis : dementia, grandiose delusions

- Temporal lobe epilepsy : flights of ideas, automatism

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Biological psychiatry : drugs acting on the brain

Discovery of drugs which were truly effective in treating psychiatric disease

• These drugs acted on the brain

• Indicated that disorders of the mind could involve abnormalities of the brain

Drugs causing abnormalities similar to psychiatric disorders

• Hallucinogenic drugs : e.g. LSD

• Psychotogenic drugs : e.g. amphetamine, cocaine

Questioned to what extent brain and mind disordersare separate phenomena

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The impact of neuropharmacology

The effect of drugs acting on the brain on psychiatric disease

• Before 1950s many new drugs, but few directed at psychiatric disorders

• Sedatives were used, but sedation not symptom relief

• No targeted drugs, since neurobiology of psychiatric disorders unknown (many thought no neurobiology!)

Many therapies based on neurobiology were misdirected:

• Insulin coma for treating epilepsy and schizophrenia

• Psychosurgery for treating schizophrenia and depression

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Pharmacological therapy for psychiatric disease

Chlorpromazine – used for treating schizophrenia

• First drug effective at treating psychiatric symptoms

Imipramine (tricyclic) – developed from chlorpromazine

• Effective treatment for endogenous depression

Iproniazid (MAO inhibitor)

• Also effective as antidepressant

• Came from observation that certain anti-tuberculosis drugs raised mood.

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Pharmacological therapy for psychiatric disease

MAO inhibitors and depression

Lithium and mania

Dopamine receptor antagonists and schizophrenia

Benzodiazepines (e.g. valium, librium) and anxiety

By 1970s drug treatments available for all major psychiatric disorders

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Neurobiological theories for psychiatric disease

Drug treatment of psychiatric disease

Many drugs known to exacerbate psychiatric symptoms

• Reserpine and depression

• Amphetamine and schizophrenia

Indicating a link between brain structure and functionand psychiatric disease

Implying a less clear differentiation between mind and brain

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The ‘anti-psychiatry’ movement

Some unorthodox psychiatrists started listening to their patients

• Believed that what other psychiatrists took to be nonsense could have meaning

• Could give indications of what patient was going through

• e.g. RD Laing

What patients say is not meaningless!

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Brain disorder or mind disorder?

By 1970s the debate as to the origin of psychiatric disorders had polarised

• Abnormality of the mind : of mental processes

- Treated by psychotherapy, cognitive therapy or behavioural therapy

• Abnormality of the brain

- Treated with drugs

- Role of psychiatrists/psychologists to provide a safe context in which this can take place

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Brain and mind order

Most now agree that the mind is firmly anchored in the brain

• Phenomena such as speech, learning, memory, even mood and personality, have physical counterparts in the brain

• Events influence brain states directly and indirectly

• Brain states produce behaviourTherefore the polarised debate seems pointless

Rather a synthesis of these approaches is appropriate

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The current view

Biological basis for psychiatric diseases firmly established Development of alternative drugs led to a wider understanding

of their mode of action, and of the basis of disease Use of animal models has validated much of the drug discovery Causality of effects brought into question

Basic theories of deficiencies /excesses of neurochemicals ruled out as simplistic

Neurobiological changes underlying psychiatric disease likely to be subtle, and unevenly distributed

May have developmental origin

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Treatment strategies for psychiatric disease

Drug treatment reasonably effective in many psychiatric diseases

• Biological basis for disease states

Psychotherapy (e.g. cognitive behaviour therapy) well established for depression, and to some extent for schizophrenia

• Symptoms are amenable to cognitive control

• Symptoms can tell us about cognitive systems which are dysfunctional in psychiatric disease

• Has implications for treatment and for understanding normal cognitive function

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Combination therapy

Therefore it is appropriate to treat psychiatric disease:

Both

At the brain activity level, using drugs which can often reverse distressing symptoms

And

At the mental level using treatments which can help understand and deal with background social factors

Many trials suggest a combination of both drug and psychological treatments works better than each one individually

Is there a role for psychosurgery?

Prevention of relapse – continued drug use or psychotherapy?AMJY : Sept 2008

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Summary

Clinical disorders should not be considered as either psychological or biological, but as an interaction of both (‘mind & brain are one’)

Experience and behaviour are determined by activity in the brain, whether normal or abnormal

Clinical disorders are almost certainly not simple in brain terms

In principle all clinical disorders can be helped by psychological treatments. Drugs may facilitate reduction in symptoms to allow psychological treatment to be effective

Continued drug treatment may protect against relapse

Psychological treatments useful in moderating specific experiences in illness, and protecting against precipitating factors

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PS3013 Clinical Psychology:

Schizophrenia: cognitive psychology and treatment

Dr. Andrew YoungBehavioural Neuroscience Research Group

amjy1@le.ac.uk

MSB Room 305

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Symptoms of schizophrenia

Positive symptoms - unusual by presence

Hallucinations Unusual Perceptions

Delusions Unusual Beliefs

Thought disorder and inappropriate affect

Negative symptoms - unusual by absence

Net result, especially of positive symptoms:

• perceived by others as being “out of touch with reality”

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Psychotic Experiences: Hallucinations

“Any percept-like experience which

(a) occurs in the absence of appropriate stimuli,

(b) Has the full force or impact of the corresponding actual (real) perception

(c) is not amenable to direct & voluntary control by the experiencer”

(Slade & Bentall 1988 p.23)

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Psychotic Experiences: Delusions

“Belief that is firmly held on inadequate grounds, is not affected by rational argument or evidence to contrary, and is not a conventional belief which the person might be expected to hold given his/her educational & cultural background”

Oxford Textbook of Psychiatry 1991

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Psychotic Experiences: Thought disorder

Manifests in bizarre & incoherent

communication with others

Disordered discourse

“Clang” associations, shifting topics, apparent puns and metaphors

Disorganisation has been distinguished from positive symptoms (Liddle, 1987)

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Negative Symptoms

“unusual by absence of particular normal functions”

• Underactivity/apathy, e.g. lack of initiative, poor self care

• Attentional impairment, e.g. poor concentration

• Poverty of speech & speech content

• Flattened affect, loss of pleasure

Avolition, anhedonia, asociability

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Schizophrenia: DSM Criteria

For at least one week (in the absence of treatment)

• (i) Two of:

- Delusions

- Hallucinations

- Incoherence or loosening of associations

- Catatonic behaviour

- Flat/Grossly inappropriate affect

• and/or (ii) Bizarre Delusions

• and/or (iii) Prominent auditory hallucinations

- Voice or voices talking to or about the subject, especially if in the third person

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Historical Overview

c. 1900

• Emergence of the concept of dementia praecox, later termed schizophrenia (Kraepelin, Bleuler)

1950’s

• Neuroleptic (anti-schizophrenic) drugs introduced.

• Amphetamine and hallucinogenic psychoses

• Biological Models of schizophrenia

• Psychotherapy continues to be seen as of doubtful value

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More recent developments

1980’s and onward

• Limitations of Neuroleptics – side effects

• Introduction of atypical antipsychotics

• Psychological Models

• Symptom based approach

- might help to overcome limitations in available drug therapy

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Genetic evidence

Bar chart, indicating lifetime risk of being diagnosed with schizophrenia, as a function of genetic relationship to another individual so diagnosed.

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Psychological theories of schizophrenic symptoms I

Nuechterlein et al (1992)

• Impaired use of activated or working memory to cue relevance of current stimulus

Hemsley (1987, 1994a)

• Reduced influence of regular-ities of past experience on current perception (action)

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Psychological theories of schizophrenic symptoms II

Frith (1987, 1992)

• Failures of self monitoring of willed intentions => experience of alien control; attribution of inner speech to external sources.

• Impaired theory of mind => confusion of internal and external events; poor interpretation of intentions of others

• Awareness of partially processed and/or sub-threshold stimuli => hallucinations and bizarre beliefs (Bentall& Slade)

Bentall (1994)

• Strongly biased attributions for threat related stimuli => persecutory delusions

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Hallucinations

• Experienced by “normal” people as well

• Cultural differences

• Sub-vocalisation• Increase occurrence

- Unpatterned noise

- Stress & physiological arousal• Decrease occurrence

- Concurrent verbal tasks

Consider hallucinations, as an example of a symptom, which can be manipulated, and perhaps understood, in psychological terms.

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Model of Hallucinations

Beliefs & Environmental Stress

Expectations Noise

Perceived Discrimination Classification

Event (real or imaginary)

(internal or external)

Reinforcement

Anxiety Reduction

(Slade & Bentall 1988)

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Misattribution of internally generated events

Different theories about mechanism

• Cognitive Deficit

- impairment in perception, memory & attention

• Bias

- Pay attention to particular types of information more than others,

- interpret information differently, possibly due to life experiences etc.

- (not a cognitive deficit, because it represents an unusual interpretation of normally processed data)

Why do people misattribute internally generated events to external or alien sources?

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Bias Theory

Halllucinators have a bias towards detecting external stimuli

Signal Detection - Bentall & Slade (1985)

• Hallucinators have a bias towards attributing their own thoughts to external sources

Reality/Source Monitoring - Bentall et al (1991)

• Biases will be more pronounced for emotional verbal material than neutral material

Distraction and Focussing

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Distraction

• Introduce techniques, monitor, review & problem solve

- Personal stereo (music, radio. TV)

- Mental games & reading

- Activity scheduling

Collaboration/Monitoring/Problem Solving

Distraction • Assumption: If hallucinations arise from over-attention and

bias towards real events, then distraction will reduce attention to them.

• Aims: Develop and incorporate strategies to distract from and therefore reduce the voices

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Focusing I

Focusing • Assumption: If hallucinations arise from misattribution of

internal events, attention to the experience and beliefs around it will reduce misattribution and increase reality monitoring

• Aims: Gradually expose client to the experience and meaning of the hallucinations and develop strategies to help client deal with hallucinations

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Focusing II

Gradual exposure• Physical Characteristics -- Content• Thoughts -- Meaning

Formulation; Interventions developedChadwick and Birchwood (1996)

• Limitations of the relationship between content of voices & emotions and coping

• Importance of beliefs about voices• Strategies for challenging beliefs about voices

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Vulnerability/stress model

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Stress and the family environment

Brown et al (1958) followed patients discharged from large psychiatric hospital

Patients who returned home had higher relapse rates than people who lived alone or in hostels

Importance of the family atmosphere in the course of schizophrenia

The family environment may be a source of stress

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Expressed Emotion (from Camberwell Family Interview)

Identified five key dimensions in expressed emotions

• Hostility

- Rejection & generalised negative comments

• Critical Comments

- Frequency of critical comments

• Emotional Over Involvement

- Exaggerated emotional response

• Positive Comments

- Statements of approval, praise, appreciation

• Warmth

- Warmth expressed

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Expressed emotion and relapse

Key Factors• Hostility• Critical Comments• Emotional Over Involvement

Patients returning to families high on these dimensions had more likelyhood of relapse

• Independent of illness severity

Review 20 prospective studies (Kavanagh, 1992)High EE Relapse 48%Low EE Relapse 21%

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Expressed emotion and physiological arousal

Measure arousal of sympathetic nervous system when face to face with High or Low EE relatives

• High EE Level of arousal maintained/increased

• Low EE Level of arousal decreased

• Change in physiological arousal when family moved from High EE to Low EE

Supports argument that high EE represents stressful environment

• Increases physiological arousal

• Increased stress

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Family Interventions

Psycho-Education

• Nature of schizophrenia; vulnerability-stress model Communication Skills

• More effective communication Problem Solving

• Defining problem; solution; planning Stress Management

• Help families identify and cope with stress Goal Setting

• Identify goals; set plans to achieve them

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A cognitive therapy perspective on psychosis

It can be useful to understand the life predicament of a person with psychosis as one of coping with illness

Psychosis is experienced by the patient as altered thoughts and feelings

Various types of psychological processes may be involved in the formation and maintenance of psychotic symptoms, different in different cases

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Adapting cognitive behaviour therapy for psychosis from CBT for other disorders

Psychotic disorders are very severe Psychotic disorders are very heterogeneous Some clinical problems are due to, or at least present as,

cognitive deficits Some clinical problems are associated with emotional

sensitivity Some clinical problems are associated with lack of trust and

misinterpretations of the therapist Some clinical problems are associated with strongly held

delusional ideas

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Conclusions I

Schizophrenia does appear to have a biological basis, and in most cases, to respond to drug treatment.

This helps us to have some idea of the brain areas and transmitter systems involved, in at least the expression of symptoms.

Symptoms are not meaningless, either to the patients, or in allowing us to hypothesise which cognitive systems have gone awry.

• Possible link to consciousness?

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Conclusions II

Symptoms are amenable to modification by psychological interventions, which can be guided by these theories.

The overall state of the sufferer is not independent of the outside world, and reflect the emotional situation of the patient.

CBT, usually used with drugs, can materially aid adjustment, recovery of social function, and also prevent, or at least delay, relapse.

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