Antipsychotic medications, which are also known as neuroleptics and major tranquilizers, belong to several different chemical groups but are similar in their therapeutic effects. These medications have a calming effect that is valuable in the relief of agitation, excitement, and violent behavior in persons with psychoses. The drugs are quite successful in reducing the symptoms of schizophrenia, mania, and delirium, and they are used in combination with antidepressants to treat psychotic depression. The drugs suppress hallucinations and delusions, alleviate disordered or disorganized thinking, improve the patient’s lucidity, and generally make an individual more receptive to psychotherapy. Patients who have previously been agitated, intractable, or grossly delusional become noticeably calmer, quieter, and more rational when maintained on these drugs. The medications have enabled many patients with episodic psychoses to have shorter stays in hospitals and have allowed many other patients who would have been permanently confined to institutions to live in the outside world. The antipsychotics differ in their unwanted effects: some are more likely to make the patient drowsy; some to alter blood pressure or heart rate; and some to cause tremor or slowness of movement.
In the treatment of schizophrenia, antipsychotic drugs partially or completely control such symptoms as delusions and hallucinations. They also protect the patient who has recovered from an acute episode of the mental illness from suffering a relapse. The medications can also treat social withdrawal, apathy, blunted emotional capacity, and the other psychological deficits characteristic of the chronic stage of the illness.
No single drug seems to be outstanding in the treatment of schizophrenia. In an individual patient, one drug may be preferred to another because it produces less-severe unwanted effects, and the dose of any one drug needed to produce a therapeutic effect varies widely from patient to patient. Because of these individual differences, it is common for psychiatrists to substitute a drug of a different chemical group when one drug has been shown to be ineffective despite its use in adequate dosage for several weeks.
In an acute psychotic episode, a drug such as chlorpromazine, olanzapine, or haloperidol usually has a calming effect within a day or two. The control of psychotic symptoms such as hallucinations or disordered thinking may take weeks. The appropriate dosage has to be determined for each patient by cautiously increasing the dose until a therapeutic effect is achieved without unacceptable side effects.
It is not known exactly how antipsychotic medications work. One theory is that they affect the release of certain neurotransmitters in the brain, such as serotonin and dopamine. These chemical messengers are produced by certain nerve cells that influence the function of other nerve cells by interacting with receptors in their cell membranes. Dopamine-receptor blockade is responsible for the main side effects of first-generation antipsychotic medications. These symptoms, which are called extrapyramidal symptoms (EPS), resemble those of Parkinson disease and include tremor of the limbs, bradykinesia (slowness of movement with loss of facial expression, absence of arm-swinging during walking, and a general muscular rigidity), dystonia (sudden sustained contraction of muscle groups, causing abnormal postures), akathisia (a subjective feeling of restlessness leading to an inability to keep still), and tardive dyskinesia (involuntary movements, particularly involving the lips and tongue). Most extrapyramidal symptoms disappear when the drug is withdrawn. Tardive dyskinesia occurs late in the drug treatment and in about half of the cases persists even after the drug is no longer used. There is no satisfactory treatment for severe tardive dyskinesia.
Antianxiety agents
The drugs most commonly used in the treatment of anxiety are the benzodiazepines, which have replaced the barbiturates because of their vastly greater safety. Benzodiazepines differ from one another in duration of action rather than in effectiveness. Smaller doses have a calming effect and alleviate both the physical and psychological symptoms of anxiety. Larger doses induce sleep, and some benzodiazepines are marketed as hypnotics. The benzodiazepines were once among the most widely prescribed drugs in the developed world.
The side effects of these medications are usually few—most often drowsiness and unsteadiness. Benzodiazepines are not lethal even in very large overdoses, but they increase the sedative effects of alcohol and other drugs. The benzodiazepines are basically intended for short- or medium-term use, since the body develops a tolerance to them that reduces their effectiveness and necessitates the use of progressively larger doses. Dependence on them may also occur, even in moderate dosages, and withdrawal symptoms have been observed in those who have used the drugs for only four to six weeks. In patients who have taken a benzodiazepine for many months or longer, withdrawal symptoms occur in 15 to 40 percent of the cases and may take weeks or months to subside.
Withdrawal symptoms from benzodiazepines are of three kinds. Such severe symptoms as delirium or convulsions are rare. Frequently the symptoms involve a renewal or increase of the anxiety itself. Many patients also experience other symptoms, such as hypersensitivity to noise and light as well as muscle twitching. As a result, many long-term users continue to take the drug not because of persistent anxiety but because the withdrawal symptoms are too unpleasant.
Because of the danger of dependence, benzodiazepines should be taken in the lowest possible dose for no more than a few weeks. For longer periods they should be taken intermittently, and only when the anxiety is severe.
Benzodiazepines act on specialized receptors in the brain that are adjacent to receptors for a neurotransmitter called gamma-aminobutyric acid (GABA), which inhibits anxiety. It is possible that the interaction of benzodiazepines with these receptors facilitates the inhibitory (anxiety-suppressing) action of GABA within the brain.
Antidepressant agents
Many persons suffering from depression gain symptomatic relief from treatment with an antidepressant. There are several classes of antidepressant drugs, which vary in their mechanism of action and side effects. Successful treatment with such drugs relieves all the symptoms of depression, including disturbances of sleep and appetite, loss of sexual desire, and decreased energy, interest, and concentration. It usually takes two to three weeks for an antidepressant to improve a person’s depressed mood significantly. Once a good response has been achieved, the drug should be continued for a further six months to reduce the risk of relapse. Antidepressants are also effective in treating other mental disorders such as panic disorder, agoraphobia, obsessive-compulsive disorder, and bulimia nervosa.
It is widely theorized that depression is partly caused by reduced quantities or reduced activity of one or more neurotransmitters in the brain. Selective serotonin reuptake inhibitors (SSRIs), which include fluoxetine (Prozac) and sertraline (Zoloft), are thought to act by inhibiting the reabsorption of the neurotransmitter serotonin. As a result, there is an accumulation of serotonin in the brain, a change that may be important in elevating mood. Because SSRIs interfere with only one neurotransmitter system, they have fewer, and less-severe, side effects than other classes of antidepressants, which inhibit the action of several neurotransmitters. Common side effects of SSRIs include decreased sexual drive or ability, diarrhea, insomnia, headache, and nausea.
Tricyclic antidepressants interfere with the reuptake of norepinephrine, serotonin, and dopamine. The side effects of these drugs are mostly due to their interference with the function of the autonomic nervous system and may include dryness of the mouth, blurred vision, constipation, and difficulty urinating. Weight gain can be a distressing side effect in persons taking a tricyclic for a long period of time. In elderly persons these drugs can cause delirium. Certain tricyclics interfere with conduction in heart muscle, and so they are best avoided in individuals with heart disease. Drug interactions occur with tricyclics, the most important being their interference with the action of certain drugs used in the treatment of high blood pressure.
Monoamine oxidase inhibitors (MAOIs) interfere with the action of monoamine oxidase, an enzyme involved in the breakdown of norepinephrine and serotonin. As a result, these neurotransmitters accumulate within nerve cells and presumably leak out onto receptors. The side effects of these drugs include daytime drowsiness, insomnia, and a fall in blood pressure when changing position. The MAOIs interact dangerously with various other drugs, including narcotics and some over-the-counter drugs used in treating colds. Persons taking an MAOI must avoid certain foods containing tyramine or other naturally occurring amines, which can cause a severe rise in blood pressure leading to headaches and even to stroke. Tyramine occurs in cheese, Chianti and other red wines, well-cured meats, and foods that contain monosodium glutamate (MSG).
Different antidepressants, such as bupropion (Wellbutrin), are chemically unrelated to the other classes of antidepressants and presumably exert their effects through different mechanisms.
Mood-stabilizing drugs
Lithium, usually administered as its carbonate in several small doses per day, is effective in the treatment of an episode of mania. It can drastically reduce the elation, overexcitement, grandiosity, paranoia, irritability, and flights of ideas typical of people in the manic state. It has little or no effect for several days, however, and a therapeutic dose is rather close to a toxic dose. In severe episodes antipsychotic drugs may also be used. Lithium also has an antidepressant action in some patients with melancholia.
The most important use of lithium is in the maintenance treatment of patients with bipolar disorder or with recurrent depression. When given while the patient is well, lithium may prevent further mood swings, or it may reduce either their frequency or their severity. Its mode of action is unknown. Treatment begins with a small dose that is gradually increased until a specified concentration of lithium in the blood is reached. Blood tests to determine this are carried out weekly in the early stages of treatment and later every two to three months. It may take as long as a year for lithium to become fully effective.
The toxic effects of lithium, which usually occur when there are high concentrations of it in the blood, include drowsiness, coarse tremors, vomiting, diarrhea, incoordination of movement, and, with still higher blood concentrations, convulsions, coma, and death. At therapeutic blood concentrations, lithium’s side effects include fine tremors (which can be alleviated by propranolol), weight gain, passing increased amounts of urine with consequent increased thirst, and reduced thyroid function.
Carbamazepine, an anticonvulsant drug, has been shown to be effective in the treatment of mania and in the maintenance treatment of bipolar disorder. It may be combined with lithium in patients with bipolar disorder who fail to respond to either drug alone. Divalproex, another anticonvulsant, is also used in the treatment of mania.
Electroconvulsive treatment
In electroconvulsive therapy (ECT), also called shock therapy, a seizure is induced in a patient by passing a mild electric current through the brain. The mode of action of ECT is not understood. Several studies have shown that ECT is effective in treating patients with severe depression, acute mania, and some types of schizophrenia. However, the procedure remains controversial and is used only if all other methods of treatment have failed.
Prior to the administration of ECT, the patient is given an intravenous injection of an anesthetic in order to induce sleep and then is administered an injection of a muscle relaxant in order to reduce muscular contractions during the treatment. The electrical current is then applied to the brain. In bilateral ECT this is done by applying an electrode to each side of the head; in unilateral ECT both electrodes are placed over the nondominant cerebral hemisphere—i.e., the right side of the head in a right-handed person. Unilateral ECT produces noticeably less confusion and memory impairment in patients, but more treatments may be needed. Patients recover consciousness rapidly after the treatment but may be confused and may experience a mild headache for an hour or two.
ECT treatments are normally given two or three times a week in the treatment of patients with depression. The number of electroconvulsive treatments required to treat depression is usually between six and 12. Some patients improve after the first treatment, others only after several. Once a program of ECT has been successfully completed, maintenance treatment with an antidepressant significantly decreases the patient’s risk of relapse.
ECT is often considered for cases of severe depression when the patient’s life is endangered because of refusal of food and fluids or because of serious risk of suicide, as well as in cases of postpartum depression, when it is desirable to reunite the mother and baby as soon as possible. ECT is often used in treating patients whose depression has not responded to adequate dosages of antidepressants.
The chief unwanted effect of ECT is impairment of memory. Some patients report memory gaps covering the period just before treatment, but others lose memories from several months before treatment. Many patients have memory difficulties for a few days or even a few weeks after completion of the treatment so that they forget appointments, phone numbers, and the like. These difficulties are transient and disappear rapidly in the vast majority of patients. Occasionally, however, patients complain of permanent memory impairment after ECT.
Psychosurgery
Psychosurgery is the destruction of groups of nerve cells or nerve fibers in the brain by surgical techniques in an attempt to relieve severe psychiatric symptoms. The removal of a brain tumor that is causing psychiatric symptoms is not an example of psychosurgery.
The classical technique of bilateral prefrontal leucotomy (lobotomy) is no longer performed because of its frequent undesirable effects on physical and mental health, in particular the development of epilepsy and the appearance of permanent, undesirable changes in personality. The latter include increased apathy and passivity, lack of initiative, and a generally decreased depth and intensity of the person’s emotional responses to life. The procedure was used to treat chronically self-destructive, delusional, agitated, or violent psychotic patients. Stereotaxic surgical techniques have been developed that enable the surgeon to insert metal probes in specific parts of the brain; small areas of nerve cells or fibers are then destroyed by the implantation of a radioactive substance (usually yttrium) or by the application of heat or cold.
Proponents of psychosurgery claim that it is effective in treating some patients with severe and intractable obsessive-compulsive disorder and that it may improve the behavior of abnormally aggressive patients. However, many of the therapeutic effects that were claimed for psychosurgery by its adherents are attainable by the use of antipsychotic and antidepressant medications. Psychosurgery has a very small part to play in psychiatric treatment when the prolonged use of other forms of treatment has been unsuccessful and the patient is chronically and severely distressed or tormented by psychiatric symptoms. Whereas ECT is a routine treatment in certain specified conditions, psychosurgery is, at best, a last resort.
The psychotherapies
Psychotherapy involves treating mental disorders, adjustment problems, or psychological distress through psychological techniques, any of which is employed by a trained therapist who adheres to a particular theory of both symptom causation and symptom relief. American psychiatrist Jerome D. Frank classified psychotherapies into “religio-magical” and “empirico-scientific” categories, with religio-magical approaches relying on the shared beliefs of the therapist and patient in spiritual or other supernatural processes or powers. This article is concerned, however, with the latter forms of psychotherapy—those that have been developed through scientific psychology and are implemented by a member of one of the mental health professions, such as a psychiatrist or a clinical psychologist. As Frank pointed out, however, the processes underlying religio-magical and empirico-scientific forms of psychotherapy are often quite similar. In addition, the seemingly different forms of scientific psychotherapy have a great deal in common with each other with respect to the factors responsible for their effectiveness. This point of view is called the “common factors” perspective on psychotherapy.
Psychotherapeutic approaches
The many forms of psychotherapy may be conveniently grouped into a few theoretical “families.” These include dynamic, humanistic and existential, behavioral, cognitive, and interpersonal psychotherapies. Dynamic therapy, based on psychoanalysis, concentrates on understanding the meaning of symptoms and understanding the emotional conflicts within the patient that may be causing them. Humanistic and existential therapies use as their primary tool the current relationship between therapist and patient to explore emotional issues in an atmosphere of empathy and support. Behavior therapy uses a variety of interventions based on learning theory to alter the overt symptoms (e.g., undesirable behavior) of the patient. Cognitive therapy uses logical analysis to identify and alter the maladaptive thinking underlying the symptoms. Interpersonal therapy focuses on problems that occur in one’s interaction with others, and it often studies symptoms in a specific social context, such as the couple or the family.
Dynamic psychotherapies
There are many variants of dynamic psychotherapy, most of which ultimately derive from the basic precepts of psychoanalysis. The fundamental approach of most dynamic psychotherapies can be traced to three basic theoretical principles or assertions: (1) human behavior is prompted chiefly by emotional considerations, but insight and self-understanding are necessary to modify and control such behavior and its underlying aims; (2) a significant proportion of human emotion is not normally accessible to one’s personal awareness or introspection, being rooted in the unconscious, those portions of the mind beneath the level of consciousness; and (3) any process that makes available to a person’s conscious awareness the true significance of emotional conflicts and tensions that were hitherto held in the unconscious will thereby produce heightened awareness and increased stability and emotional control. The classic dynamic psychotherapies are relatively intensive talking treatments that are aimed at providing patients with insight into their own conscious and unconscious mental processes, with the ultimate goal of enabling them to achieve better self-understanding.
Dynamic psychotherapy attempts to enhance the patient’s personality growth as well as to alleviate symptoms. The main therapeutic forces are activated in the relationship between patient and therapist and depend not only upon the empathy, understanding, integrity, and concern demonstrated by the therapist but also upon the motivation, intelligence, and capacity for achieving insight exhibited by the patient. The attainment of a therapeutic alliance—i.e., a working relationship between patient and therapist that is based on mutual respect, trust, and confidence—provides the context in which the patient’s problems can be worked through and resolved. Several of the most important forms are treated below.
Psychoanalytic psychotherapy
Classical psychoanalysis is the most intensive of all psychotherapies in terms of time, cost, and effort. It is conducted with the patient lying on a couch and with the analyst seated out of sight but close enough to hear what the patient says. The treatment sessions last 50 minutes and are usually held four or five times a week for at least three years. The primary technique used in psychoanalysis and in other dynamic psychotherapies to enable unconscious material to enter the patient’s consciousness is that of “free association.” (See association test.) In free association, according to Freud, the patient
is to tell us not only what he can say intentionally and willingly, what will give him relief like a confession, but everything else as well that his self-observation yields him, everything that comes into his head, even if it is disagreeable for him to say it, even if it seems to him unimportant or actually nonsensical.
Such a procedure is rendered difficult, first because the voicing of one’s innermost (and often socially unacceptable) thoughts is a departure from years of experience spent carefully selecting what will be said to others. Free association is also difficult because the patient might resist recalling repressed experiences or feelings that are connected with intense or conflicting emotions the patient has never resolved or settled. Such repressed emotions or memories usually revolve around the patient’s important personal relationships and innermost feelings of self; consequently, the release or recollection of such emotions in the course of treatment can be intensely disturbing.
Through attentive listening and empathy, the therapist helps the patient express thoughts and feelings that in turn permit the unearthing of underlying emotional conflicts. In the course of treatment, however, there likely will be many points at which the patient seems to block progress—for example, by forgetting, growing confused, becoming overly compliant or noncompliant, intellectualizing, and so on. This is called resistance. Another phenomenon, known as transference, occurs when the patient projects (attributes to someone or something else) onto the therapist feelings that the patient has experienced in earlier significant relationships—e.g., love or hatred, dependence or rebellion, and rivalry or rejection. These feelings may include the disturbing emotions felt in the therapeutic process of recollection and free association, with the psychoanalyst almost invariably becoming the focus of such projection; that is, the patient is likely to blame any immediate emotional distress on the analyst. To facilitate the development of transference, the analyst endeavors to maintain a neutral stance toward the patient, becoming an effective “blank screen” onto which the patient can project inner feelings. The analyst’s handling of the transference situation is of vital importance in psychoanalysis—or, indeed, in any form of dynamic psychotherapy. It is through such resistance and transference that the patient discovers the nature of unconscious feelings and then becomes able to acknowledge them. Once this has been done, the person is often able to regard these inner feelings in a far more dispassionate and tolerant light and can experience a sense of liberation from their influence on future behavior.
A major therapeutic tool in the course of treatment is interpretation. This technique helps patients become aware of any previously repressed aspect of emotional conflict (as reflected in resistance) and to uncover the meaning of uncomfortable feelings evoked by transference. Interpretation is also used to determine the underlying psychological meaning of a patient’s dreams, which are held to have a hidden or latent content that may symbolize and indirectly express aspects of emotional conflict.
Individual dynamic psychotherapy
Although the influence of psychoanalysis, particularly on American psychiatry, was profound, it began to wane in the 1970s. Since then, those seeking treatment have tended to choose short-term individual dynamic therapy over psychoanalysis. This form of therapy is usually more accessible and less costly than psychoanalysis, and it typically requires no more than a series of weekly sessions (lasting approximately one hour) over the course of several months. The aim of treatment, as in psychoanalysis, is to increase the patient’s insight (self-understanding), to relieve symptoms, and to improve psychological functioning. Additionally, the therapist provides the patient with a sense of support and a structured means of identifying problems and achieving solutions. Suitable patients include those who experience any of a wide range of psychological and personality disorders or adjustment problems and who wish to change; the patients must, however, be able to view their problems in psychological terms.
As in psychoanalysis, patients learn to trust the therapist so that they are able to speak candidly and honestly about their most intimate thoughts and feelings. The treatment setting, however, is, less formal than that of psychoanalysis, and it more closely resembles arrangements used in other forms of psychotherapy (e.g., with the therapist and patient seated so that eye contact can be achieved if desired).
Therapists use treatment techniques such as free association and interpretation to analyze a patient’s resistances, transference, and dreams. As opposed to classical psychoanalysis, the focus of interpretation is much more likely to be on resistance than on transference. The therapist directs the patient’s attention to meaningful yet unconscious links between present and past experiences, as well as to seemingly unrelated aspects of the patient’s current life patterns. The overall treatment goal, as in psychoanalysis proper, is the achievement of increased insight and rational control over previously unconscious aspects of the patient’s life and the accompanying relief of symptoms.
Brief focal psychotherapy
This is a form of short-term dynamic therapy in which a time limit to the duration of the therapy is often established at the outset. Sessions lasting 30 to 60 minutes are held weekly for, typically, five to 15 weeks. At the beginning of treatment the therapist helps identify the patient’s problem or problems, and these are made the focus of the treatment. The problem should be an important source of distress to the patient and should be modifiable within the time limit. The therapist is more active, directive, and confrontational than in long-term dynamic therapy and ensures that the patient keeps to the focus of treatment and is not diverted by subsidiary problems or concerns.
Humanistic and existential psychotherapies
In contrast to dynamic psychotherapy, humanistic and existential psychotherapies focus on the current experience of the patient in resolving problems. Humanistic therapy is represented primarily by the person-centered approach of American psychologist Carl Rogers, who held that the essential features of therapy are the characteristics of the relationship created by the therapist (as opposed to the therapist’s specific interventions). In Rogers’s view, these characteristics—empathy, warmth, and a nonjudgmental attitude—are sufficient to produce therapeutic change, given the patient’s natural propensity for personal growth and healthy functioning. This belief in the patient’s inherent capacity for growth is the basic tenet of humanistic psychology.
Existential therapies are various in style, although each is concerned in one way or another with the meaning of the patient’s current experience and larger existence. In addition, all existential therapies emphasize the importance of the therapeutic relationship as an authentic, “real” medium in which patients can discover themselves. Approaches such as the Gestalt therapy of German American psychiatrist Frederick S. Perls involve confronting the patient’s behavior in the immediate here and now of the patient’s experience. Others, such as the existential approach of Austrian American psychiatrist Viktor Frankl, appear more intellectually inquisitive regarding meaning and values, though they are still directed toward the patient’s immediate experience. Rather than use interpretation in the psychoanalytic sense to uncover unconscious material and supply meaning for the patient, humanistic and existential therapies seek to help patients discover their own meanings through collaborative effort with a supportive, yet often bluntly candid, therapist.
