Tag Archives: electroconvulsive treatment

Comparing Parnaoid Schizophrenia and Delusional Disorder

In comparing delusional disorder and paranoid schizophrenia I noticed that paranoid schizophrenia is actually a step or two further than delusional disorder, even though these two disorders are not related.

The delusions in delusional disorder are not out of the ordinary meaning the delusion a person is currently suffering from could actually happen, but is still considered to be slightly farfetched.  Generally the delusion is something that does not happen to a large amount of people.  The disorder is generally undetectable until the person suffering from it decides to talk about what they feel is happening to them.  This is because the person suffering from delusional disorder had no abnormal behavior and there are either no or very minimal hallucinations.  People suffering from this disorder usually have a scapegoat.  That is, they can always find a way for things that go wrong to be someone else’s fault rather than accept responsibility.  There are several subtypes of delusional disorder.  People suffering from persecutory delusional disorder believe other people are out to get them.

Erotomanic sufferers walk around proclaiming that there is someone of importance is secretly in love with them.  The grandiose delusion disorder causes a person to believe that they are extremely important, or that they have some type of super human powers.  Where the somatic delusion disorder occurs the person believes there is something significantly wrong with their own body, and with the jealous subtype the person believes their spouse has cheated on them even when there is no evidence to support that.

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Research supports findings that a genetic link to a close relative who suffers from delusional disorder is possible.  Another cause could be dysfunctional cognitive processing, in which the patient has a indistinguishable way of looking at life.  The speculations they develop are by assuming everything instead of fact checking.  Another cause could be through stress, through being unable to handle stressful situations.  Treatment for delusional disorder most often involves an antipsychotic medication and sometimes involves therapy either on an individual level or on a familiar level, but treatment is only as successful as the patient allows it to be.

Paranoid schizophrenia patients do not have hallucinations that are possible, the hallucinations these patients suffer from are a much distorted view of their own reality.  There are various symptoms for paranoid schizophrenia patients; these can include auditory hallucinations, anxiety, anger, having a patronizing manner and serious thoughts of suicide, along with suicidal behavior.  These people are less affected by these kinds of symptoms and are generally more affected by what are known as positive symptoms, which are symptoms that are point toward a loss of the knowledge of what reality is.  This usually involves an abnormal view.  While the cause of this disorder is unknown, there is evidence to imply that it is caused by a brain dysfunction and that there are factors which increase the likely hood of paranoid schizophrenia.  These factors seem to be things that people would be unable to avoid, like having a family history or being exposed to viruses in the womb or being malnourished in the womb, or having severe trauma such as childhood abuse.  Even with such early risk factors taking place, paranoid schizophrenia is not generally seen until sometime between the teenage years and the mid-thirties.

Several treatments are available for this disorder but there is no cure, so treatment is there to help people learn how to cope and to learn life skills so they can have a full and productive life.  There are medications which are antipsychotics and they have two different levels.  Tier one medications are typical and have been found to be effective in helping a patient with the positive symptoms such as delusions and hallucination.  There is a side effect of some movements which are completely uncontrolled and seem erratic.  The second generation antipsychotics are atypical and help the patient cope with hallucinations and delusions as well as helping with increasing drive.  The side effect for these medications however is a slow in the metabolism, resulting in weight gain, or worse.  Other treatments available are psychotherapy which is usually recommended with the use of medications and can include social and vocational skills training.  ECT or electroconvulsive therapy and hospitalization are also available if the patient and the therapist feel they are appropriate.  If this disorder is left untreated, adverse affects may start to become visible.  Symptoms become much worse and turn into dangerous and/or deviant behavior.  Abuse of alcohol or drugs may become prevalent, family conflicts, self destructive behavior which can then lead to poverty, homelessness and health problems.  Any of these behaviors can lead to incarceration.

These two disorders seem to have a lot of similarities but in reality they are very different in almost every way including the outcomes of each one.  A more in depth article would be able to show the variations of each in a much better light.

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Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Delusional Disorder. Psych-uknet.com.  http://psychnet-uk.com/dsm_iv/delusional_disorder.htm

Paranoid Schizophrenia.  Mayoclinic.com.  http://mayoclinic.com/health/paranoid-schizophrenia/DS00862

Paranoid Schizophrenia. Schizophrenia.com  http://www.schizophrenia.com/szparanoid.htm

What Kind of Therapy is Out There?

In reviewing treatments for depression, it seems the three most common, two of which are very broad, treatments are anti depressant medications, electro-convulsive therapy or ECT, and psychotherapy. Each of these treatments has their own purpose and regimen and can be combined in various ways even though they are different. In fact it is most likely because they are so different that they work well together.

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Antidepressant medication gives a therapist and a patient many options. These options have both positive and negative effects. There are different side effects with each type of medication, some tolerable, some need to be managed with other medications. It is different for everyone; this is why it is important to continue trying different combinations until an agreeable treatment plan is found. One example of medication is SSRIS, which are Selective Serotonin Reuptake Inhibitors. This medication is usually the first choice for treatment. The reasoning behind this is that SSRI’s are the most tolerated with very little side effects and most people find they work very well for them. Some side effects are headache or insomnia, but often any side effects subside in the first month. This medication allows a high amount of serotonin to be blocked in the synapse. By doing this, the cells that are neglected are resaturated allowing relief from depression symptoms.

Tricyclic anti-depressants or TCAs are a second choice in medications, if for some reason the SSRI is unable to help the patient. This medication was developed sometime during the 1950’s and 60’s. TCAs seem to be used for more moderate or severe depression because the side effects are more likely to be serious. TCAs work in the brain synapses and increase norepinephrine. Some of the side effects include dry mouth or visual focus, but the more serious side effects include things such as urinary obstruction or delirium. People who have had a lot of strokes or have been diagnosed as having seizure disorders should not be given any TCAs as medication.

MAOIs or monoamine oxidase inhibitors are another common medication prescribed to depression patients. These are generally a last choice because the side effects are often serious. MAOIs are usually effective in treating depression and were actually the first anti-depressant. It works by blocking monoamine oxidase in the brain synapses and increasing norepinephrine. MAOIs inhibit the body’s ability to break down tyramine which is found in very common foods such as wine, nuts, and chocolate. When this food is consumed while the person is taking an MAOI, it is possible for the tyramine to cause blood pressure to rise to dangerous levels.

While anti-depressants can be mixed or left as a single treatment, they do provide a lot of options to help deal with side effects or other issues that may come up.  They are always the best option; another treatment option for depression is electroconvulsive therapy or ECT.

When electroconvulsive therapy is chosen as treatment the patient receives an electrical current which is passed through the brain causing a seizure. The seizure usually continues for twenty to ninety seconds. This treatment is said to offer a patient a quick relief of their depression symptoms. A common side effect of this treatment is confusion that can last up to several hours and short term memory loss, both of which are short term.

Psychotherapy is the last type of treatment discussed and is often referred to as talk therapy. There are various types of psychotherapy such as cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy. The most common type of talk therapy is the cognitive behavioral therapy. During sessions a patient not only talks about their depression, they have the opportunity to learn more about it. The patient is then able to focus on knowing what their negative patterns are and changing those into positive behaviors. Interpersonal therapists’ help their patients look at the destructive relationships a person is in that may be helping to grow the depression instead of helping to keep it at bay. Psychodynamic therapy helps a patient work through and resolves whatever internal conflicts the patient may be living with.

All of these types of psychotherapy focus on one thing, helping the patient talk through and learn how to deal with events in their lives so they don’t feel like they are drowning in depression.

Out of all of these treatments I would actually think electroconvulsive therapy to be the quickest and most effective. I can’t imagine going under sedation in order to endure treatment and then waking up not only with memory loss but also being confused about your whereabouts, among other things, even if only temporarily.

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Child and Adolescent Psychological Disorders.

Oxford Textbook of Psychopathology.

Depression. medicinenet.com. http://www.medicinenet.com/script/main/art.asp?articlekey=342&pf=3&page=6

Depression (Major Depression).  Mayoclinic.com. http://www.mayoclinic.com/health/depression/DS00175/METHOD=print&DSECTION=all

Is There More Than One Kind Of Depression?

Dysthymic Disorder and Major Depressive Disorder are actually two different versions of depression.  Dysthymic Disorder is noted for chronic depression.

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The definition for Dysthymic Disorder is that it is a “mood disorder with chronic depressive symptoms that are present most of the day, more days than not, for a period of at least two years.”  (Minddisorders.com).  The symptoms are usually present for years and can include low self esteem, decreased motivation, change in sleeping patterns and change in appetite patterns.  Causes of this type of depression are things like a person’s upbringing.  If a person is brought up in a home where abuse is prevalent an adult can suffer from depression for their entire life.  Treatment for this type of depression is generally psychotherapy but sometimes is combined with antidepressants.

Similarly Major Depressive Disorder is the next level of depression and is defined as, “a condition characterized by a long lasting depressed mood or marked loss of interest or pleasure in all or nearly all activities” (Minddisorder.com).   This form of depression has an intense impact on a person’s life.  It usually comes about when a person suffers a traumatic event, but this does not always happen.  Symptoms can include a disturbed mood throughout most of the day, a change in the sleep pattern, a change in the appetite pattern, a loss of interest in things that are considered pleasurable, but then go further to include problems when trying to concentrate or think in depth, psychomotor retardation or agitation and thoughts of suicide.  If this form of depression is left untreated it can last longer than four months and recurrence is eminent.  Treatments for Major Depressive Disorder include psychotherapy or talk therapy, electroconvulsive therapy or ECT and antidepressant medications or a combination of these treatments.

Nearly everything about these two disorders are similar, the main difference is that major depressive disorder is an extension of Dysthymic Disorder in that symptoms and moods are more severe therefore treatments need to be more involved and more inclusive.

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Netherton, S.D., Holmes, D., Walker, C.E., Child and Adolescent Psychological Disorders

Blaney, P.H., Millon, T., Oxford Textbook of Psychopathology.

Depression (Major Depressive Disorder) http://psychcentral.com/disorders/sx22.htm

Dysthymic Disorder. minddisorder.com.  http://www.minddisorders.com/Del-Fi/Dysthymic-disorder.html

Dissociative Identity Disorder. Psychnet-uk.com. http://www.psychnet-uk.com/dsm_iv/dissociative_identity_disorder.htm

Major Depressive Disorder. minddisorder.com. http://www.minddisorders.com/Kau-Nu/Major-depressive-disorder.html

Major Depressive Disorder (MDD) treatment options – Examining the STAR*D Trial

When weighing the effectiveness of Major Depressive Disorder (MDD) treatment options, the most logical place to start is the largest open-label pragmatic trial ever rendered; The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.  The STAR*D trial concluded that there were no statistically significant differences in short term remission or response rates between tested treatment options, including both CBT and pharmacological remedies, but that some treatment options had advantages over others in terms of side effects and/or mean time to remission.  (Sinyor, Schaffer, & Levitt, 2010)

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There are many different flavors of CBTs intended to treat mood disorders.  Those flavors include those predominantly focused on learning theory or behavioral activation (BA), predominantly cognitive models such as Cognitive Therapy (CT/CBT), and models incorporating additional elements such as Cognitive Behavioral Analysis System Psychotherapy (CBASP) and Mindfulness-Based Cognitive Behavioral Therapy (MCBT).  (Meyer & Scott, 2008, p. 685)  CBT, when practiced by inexperienced STAR*D clinicians, was at least equally effective in short term follow-ups when compared with pharmacological remedies.  CBT was also associated with significantly fewer side effects.  Those facts alone should serve as reasonable justification in recommending CBT over all other treatment methods.

CBT was associated with longer times to remission when compared with pharmacological remedies, when they were effective, so if speed of improvement is of critical importance the client could potentially benefit the pharmacological treatment option.  Despite the apparent speed with which the pharmacological agents worked, choosing which drug is no easy task.  STAR*D found no clear medication “winner” for patients whose depression does not remit after one or more aggressive medication trials.  (Gaynes, Warden, Trivedi, & Wisniewski, 2009, p. 1443)  Matter of fact, every drug and combination of drugs showed the same effect as every other drug and drug combination.  (Leventhal & Antonuccio, 2009)  Some studies suggest that use of multiple antidepressant medications may double the likelihood of remission compared with use of a single medication.  (Blier, Ward, Tremblay, & Laberge, 2010)  Guess who funded that study?

There is increasing evidence that the biological explanation and pharmacological treatment of depressions is a failure.  STAR*D provides compelling evidence to that the placebo effect is the prime explanation for favorable outcomes that occur with antidepressants.  Of the patients that were found to respond positively to pharmacotherapy on the short term, the STAR*D study found that at the end of a year’s time almost all of the patients (97%) had either relapsed or dropped out.  (Leventhal & Antonuccio, 2009)  Even if we continue to leverage the pharmacological remedies, the long-range outcomes of clients with MDD are better when CBT is included, regardless of whether CBT is concurrent with or follows pharmacotherapy.  (Friedman, Wright, Jarrett, & Thase, 2006, p. 327)  The beneficial effects of CBT persist several years into post treatment and are strongly associated with preventing relapse (Kuyken, Dalgleish, & Holden, 2007), especially among individuals discontinuing medication use.  (Friedman, 2004)

As controversial as they are, “brain stimulation therapies” like electroconvulsive treatment (ECT) are effective in days, not weeks, and most have a higher response rate than any treatment tested in the STAR*D trial.  (Insel & Wang, 2009)  While ECT is still the gold standard in brain stimulation therapies, clinicians now have a growing list of FDA approved brain stimulation interventions. “These interventions include new modifications of ECT, vagus nerve stimulation, transcranial magnetic stimulation (TMS), magnetic seizure therapy, deep brain stimulation, transcranial direct current stimulation, implanted cortical stimulation, and others on the horizon.”  (Lisanby & Novakovic, 2009, p. 734)  Studies that utilized brain stimulation therapies to treat depression revealed significant increases in the release of norepinephrine as well as increased serotonergic activity, both of which are purported to have antidepressant effects.  (Weaver, 2009)  However, ECT is use is “limited by its invasive nature, which includes the requirement of general anesthesia and the risk of retrograde amnesia, which may be irreversible in some patients.”  (Rot, Mathew, & Charney, 2009, p. 311)  As a result, brain stimulation therapies are usually reserved for cases where depression is resistant to conventional treatments.  In addition, use of brain stimulation therapy is entirely dependent on the prescribing clinician believing in a tenuous underlying premise that norepinephrine plays a key role in depression onset and recurrence.

It would suffice to say that I favor the CBT methodology of treatment for unipolar depression, in most, if not all cases.  Personally, I would endeavor to enhance the CBT experience by utilizing cutting edge technological alternatives to traditional CBT… like virtual reality, or VR, simulations.  VR simulations are computer generated environments constructed to elicit an appropriate emotional response from clients… responses we as therapists can use in therapy.  (David, 2010)  Coupling responses that rival in vivo responses with well trained and knowledgeable CBT methods, we could usher in a new alternative to the placebo effect that passes for pharmacological intervention today.  The failure of antidepressants to provide lasting benefit, and the underlying truth that 100 years of research has failed to identify an underlying physical cause for mental disorders (including depression) leads me to believe that a “biopsychosocial model may be more useful than a disease model for conceptualizing and treating depression.”  (Leventhal & Antonuccio, 2009, p. 199)

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Blier, P., Ward, H. E., Tremblay, P., & Laberge, L. (2010, Mar). Combination of antidepressant medications from treatment initiation for major depressive disorder: A double-blind randomized study. The American Journal of Psychiatry, 167(3), 281-288. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1976013231&sid=18&Fmt=4&clientId=4683&RQT=309&VName=PQD

David, D. (2010, Mar). Cutting edge deveopments in psychology: Virtual reality applications. Interview with two leading experts. Journal of Cognitive and Behavioral Psychotherapies, 10(1), 115-126. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2010171911&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, E. S., Wright, J. H., Jarrett, R. B., & Thase, M. E. (2006, May). Combining cognitive therapy and medication for mood disorders. Psychiatric Annals, 36(5), 320-329. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1069483751&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Friedman, M. A. (2004, Spring). Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clinical Psychology: Science and Practice, 11(1), 47-68. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=40&did=526558591&SrchMode=1&sid=5&Fmt=10&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272666830&clientId=4683

Gaynes, B. N., Warden, D., Trivedi, M. H., & Wisniewski, S. R. (2009, Nov). What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression. Psychiatric Services, 60(11), 1439-1445. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1921563151&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Insel, T. R., & Wang, P. S. (2009, Nov). The STAR*D trial: Revealing the need for better treatments. Psychiatric Services, 60(11), 1466-1467. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=28&did=1921563061&SrchMode=1&sid=6&Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272667182&clientId=4683

Kuyken, W., Dalgleish, T., & Holden, E. R. (2007, Jan). Advances in cognitive-behavioural therapy for unipolar depression. Canadian Journal of Psychiatry, 52(1), 5-14. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1203220561&sid=5&Fmt=3&clientId=4683&RQT=309&VName=PQD

Leventhal, A. M., & Antonuccio, D. O. (2009). On chemical imbalances, antidepressants, and the diagnosis of depression. Ethical Human Psychology and Psychiatry, 11(3), 199-214. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1923231211&sid=19&Fmt=3&clientId=4683&RQT=309&VName=PQD

Lisanby, S. H., & Novakovic, V. (2009, Jun). Brain stimulation therapies for clinicians. The American Journal of Psychiatry, 166(6), 734-736. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1738370431&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Meyer, T. D., & Scott, J. (2008, Nov). Cognitive behavioural therapy for mood disorders. Behavioural and Cognitive Psychotherapy, 36(6), 685-693. doi: 10.1017/S1352465808004761

Rot, M. A., Mathew, S. J., & Charney, D. S. (2009, Feb 3). Neurobiological mechanisms in major depressive disorder. Canadian Medical Association. Journal, 180(3), 305-313. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1634710771&sid=14&Fmt=3&clientId=4683&RQT=309&VName=PQD

Sinyor, M., Schaffer, A., & Levitt, A. (2010, Mar). The sequenced treatment alternatives to relieve depression (STAR*D) trial: A review. Canadian Journal of Psychiatry, 55(3), 126-136. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=2016794701&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Weaver, D. F. (2009, Summer). Self-induced “therapeutic seizures” for the treatment of depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 21(3), 355-357. Retrieved from http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?index=71&did=1868802651&SrchMode=1&sid=14&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1272668233&clientId=4683