Psych 4039 - Exam 3: Alternatives

Front 1

As used by the author, "alternatives" means alternative to...

Back 1

*Custodial institutionalization
*Psychoanalytic psychotherapy
(something other than analysis & warehousing)

Front 2

The 2nd Biological Psychiatry was also known as...? Why?

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*Dark Ages of Psychiatry
*b/c it was shameful due to things that were done that led to the ANTIPSYCHIATRY mvmt in USA

Front 3

Alternatives was between the years of ... & ...?

Back 3

1900
1950

Front 4

In 1900, the alternatives to custodial hospitalization & psychoanalysis were...

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*Shock Therapy
*Hydrotherapy
*Faradization
*Pharmacotherapy

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Shock Therapy

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*Physical or psychological disturbances
(Ex: Near Death Experience with use of water)
*Electrical shock to the brain to deliberately induce seizures

Front 6

Hydrotherapy

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Any use of water to treat mental illnesses
(Ex: spa or mineral bath)

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Faradization

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*application of electrical current on ppl's bodies (no electroconvulsive therapy: no seizures)
*apply to arms/legs, not head
*(Ex: cure neurasthenia)

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Pharmacotherapy

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*using drugs to treat mental illnesses
*Been around since Hippocrates

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Ancient Drug Therapies

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*Hellebore
*Laudanum
*Mercury

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Hellebore

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*Ancient
*plant that gives you diarrhea

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Laudanum

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*Ancient
*Mix of alcohol & opium
*Very addictive
*Paracelsus: von Honheim

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Mercury

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*Ancientf
*used til 19th century
*Hippocrates gave to patients in small doses
*Toxic poison; lost a # of patients
*Side effect: corpus saliva

Front 13

19th Century Drug Therapies

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*Morphine
*Hashish
*Ccaine
*Chloral Hydrate
*Bromide
*Belladonna Alkaloids (atropine, scopolamine)

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Morphine

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*19th century
*Became available ~1800
*narcotic used as a painkiller
*derived from opium
*Naturally occuring & can be taken orally

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Hashish

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*19th Century
*resin of marijuana plant
*used in mental illness treatment
*Moreau brought it back from the Middle East

Front 16

Moreau

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*Brought Hashish from Middle East where it was popular in 1840
*His work led to a book in 1850 used for mental illness & became 1st book written about psychopharmacology

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1st book about Psychopharmacology

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*written by Moreau
*1850

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Cocaine

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*19th Century
*From cacao plant
*thought injecting was safe bc directly into bloodstream (quicker/lower dosage)
*Freud advocated cocaineas a psychiatric treatment for depression & other drug addictions
*causes psychosis

Front 19

Chloral hydrate

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*Widely used in hospitals along with paraldehyde & bromide
*Synthetic substance
*Used for narcoanalysis
*Colorless, slight bitter taste; aromatic odor
*Liquid version called "knockout drops"... when added to alcohol its called "Mickey Finn"
*Potent hypnotic effects when mixed with alcohol

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Paraldehyde

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*19th Century
*Synthetic
*Less potent & less toxic than Chloral hydrate

Front 21

Bromide

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*19th Century
*Synthetic
*Depressant used to treat epilepsy
*Lighter sleep than Chloral or Paraldehyde
*May cause hangover & acute toxicity
*Chronic toxicity is frequently called bromism

Front 22

Belladonna alkaloids

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*19th Century
*Atropine & Scopolamine
*Plant derived
*means beautiful lady
*Enhances patient's pupils
*Produces delirium & sedative effect

Front 23

Alkaloids

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*Morphine, Hashish, & Cocaine are all alkaloids
*Belladonna

Front 24

Chronic Toxicity is frequently called...

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Bromism

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"New Alternatives"

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*Pharmacotherapy
*Defocalization
*Insulin coma therapy
*Metrazol convulsive therapy
*Electroconvulsive therapy
*Psychosurgery

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Pharmacotherapy 1900-1950
(Types)

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*Stimulants (Amphetamine)
*Antihistamines
*LSD (hallucinogens)
*Barbiturates (barbital - Veronal & Medinal)

Front 27

Pharmacotherapy 1900-1950
Stimulants (amphetamines)

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*for ADHD & Depression
*used for ADHD 1st
*addictive & can cause psychosis
*used by military to keep pilots awake
*treats narcolepsy

Front 28

Pharmacotherapy 1900-1950
Amphetamine Shock

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*derived from observations of patients given methamphetamine to treat barbiturate overdose.
*Prolongs euphoria, excitement, talkativeness

Front 29

Pharmacotherapy 1900-1950
Antihistamines

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*sedative
*basis for selective serotonin re-uptake inhibitor!!
*Diphenhydramine = Benadryl

Front 30

Pharmacotherapy 1900-1950
Barbiturates

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*Discovered in 1903 by Fisher & Mering
*sedative (higher therapeutic index & prolonged sleep)
*5% mortality rates at 1st
*1st type of pharmacology introduced into medicine (1905)
*Became main sedative used by psychiatrists
*treated Schiz & withdrawal from heroin
*Narcoanalysis
*Prolonged narcosis
*Depatterning

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Pharmacotherapy 1900-1950
Narcoanalysis

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*Barbiturates
*psychoanalysis of conduct of patients being treated with subhypnotic doses of sedatives
*Based on belief that drug produces disinhibition resulting in confession & expression of repressed memories
*Used as a tool of insight
*Thiopental (ultra short acting)... Amytal (intmt acting, 6-8 hours)

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Pharmacotherapy 1900-1950
Prolonged narcosis

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*Barbiturates
*1st somatic therapy of 20th century
*transport disturbed women from Japan to Shanghai
*5-9 days of deep sleep
*discovered by Macleod
*Klaesi made treatment popular for Schiz
*Bailey & Sargant put patients to sleep for months at a time.

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Pharmacotherapy 1900-1950
Bailey & Sargant

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*Put patients to sleep for months @ a time
*Highly competitive with eachother
*Many patients died (esp Bailey)
*Bailey convicted of manslaughter
*Sargant came under scrutiny for working for MI6 in "interrogation & brain control techniques"

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Pharmacotherapy 1900-1950
Depatterning

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*Barbiturates
*Patient given heavy sedative & put to sleep then treated w/ ECT & recorded messages (usually propagandic)
*"psychic driving" or "brainwashing"

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Defocalization

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*surgical removal of infected tissues or organ to treat mental illnesses

Front 36

Henry Cotton

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*Medical director of NY hospital
*theorized that from bacterial infections in the body, bacteria would produce toxins that caused mental disturbances (incorrect!)
*Defocalization & Focal Infection Theory
*Treated 1,000 patients surgically & reported 80% recovery rate
*Controlled studies disagreed
*Died of heart attack

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Focal Infection Theory

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*Henry Cotton
*Defocalization
*Focal means localized
*Infected teeth, tonsils, & colon

Front 38

Malaria Therapy

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*Fever therapy, gave patients malaria as treatment for mentall illness
*von Jauregg
*idea from improvement in the psychosis of a female mental patient after she had a strep infection
*Tuberculin Treatment: inject Tb gave high fever but switched to malaria bc could be controlled with quinine
*Watershed event in meds & psychiatry bc ^^ optimism that treatments for mental disorders could be found
*Only worked in GPI/advanced syphilis patients
*Penicillin (Fleming) made malaria therapy obsolete due to mass production

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Julius Wagner von Jauregg

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*Won Nobel Prize for Malaria Therapy
*Austrian & antisemetic

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Insulin Coma therapy
Facts

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*Use overdose of insulin to deprive the body of glucose, causing seizures & coma
*Not easy bc dangerous
*Given 5 days a week
*Sakel
*treats drug addiction
*88% recovery rate for treatment of Schiz (social remission = 18%)
*100+ Insulin coma units established in hospitals in USA & Europe by 1960

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Manfred Joshua Sakel

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*Austrian Jew
*Bc of antisemitism, went to Berlin after med school.
*Physician at Lichterfelde Sanatorium (wealthy drug addicts)
*Not well liked,
*in treating morphine withdrawal, he noticed that it decreased desire for drug & calmed agitated states

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Insulin

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protein hormone secreted by the pancreas that causes tisues to take up glucose which causes hypoglycemia
*Discovered by Banting & Best

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Banting

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*Got Nobel Prize for discovering Insulin

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Insulin Coma Therapy
Procedure

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*begun early in AM w/ inject of insulin in gluteus maximus. *Dose dependent on stage of tment; start low & increase
*Shortly after inject, patient gets quiet as brain is deprived of glucose.
*Some patients begin to perspire & drool
*Respiration & HR increase. *W/in an hour those that receive high enough doses lapse into a coma.
*Irregular m contractions
*Patient may slowly move head left to right; hand & wrist twitch; arm may extend suddenly straight up; patient sucking motion of lips resembling a nursing infant
*Such “primitive movements” thought from freeing up of lower brain centers from control of grey matter of cortex which is inhibited by the insulin.
*W/ high doses some patients have violent seizures.
*Serious judgment of how long the coma. (Too short= won't work, too long= not be revived or brain damage) Typically deep coma maintain 1 to 2 hours.
*Then given a glucose drink by mouth or intubation.

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Metrazol Convulsive Therapy

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*Meduna proposes biological antagonism btwn epilepsy & schiz
*Metrazol= cardiac Stimulant that injected causes seizures
*Colonic Tonic

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Colonic tonic

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*Metrazol Convulsive Therapy
*Patients alternate btwn hypertonic & rigidity in their muscles (patients can die or stop breathing)
*Meduna reported that it was dangerous & difficult to watch but did work

Front 47

Meduna

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*Discovered Metrazol Convulsive Therapy
*rediscovers work of Auenbrugger using camphor to produce seizures & treat bipolar disorder
*Tried camphor 1st but switched to metrazol
*Treated 26 patients by 1935

Front 48

Metrazol Convulsive Therapy made obsolete by...

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ECT

Front 49

Malaria Therapy made obsolete by...

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Penicillin

Front 50

Electroconvulsive Therapy
Developed by:

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*Ugo Cerletti

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Cerletti

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*Director of Clinic for mental & Nervous Diseases in Rome
*Interested in animal models of epilepsy
* Experimented with Metrazol Shock
*Developed a model of epilepsy in dogs using electric shock in 1933
*1938 1st clinical ECT trial to treat depression****

Front 52

Why was Cerletti interested in an animal model for seizures?

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If you can produce seizures in an animal, then you can find a treatment

Front 53

ECT

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*Rapidly made metrazol shock obsolete
*Curare

Front 54

Why didn't Cerletti like Cardiazol (Metrazol) Convulsive Therapy?

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because “consciousness is not lost immediately, and it is preceded by a sensation of asphyxia which is agonizing for the patient”

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Prevalence of side effects

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*Metrazol + ECT = fractures & dislocations
(Complication: 4.0 ... Death: ?)
*Insulin = brain damage
(Comp: 1.0... Death: 0.05)
*ECT = relatively safe
(Comp: 1.0 ... Death: 0.6)

Front 56

ECT
The Beginning: Animals

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*Bc of Cerletti's experience w/ e-induced seizures he considered applying method to patients but was concerned about safety.
*~1/2 of dogs in their exp died from cardiac arrest.
*Moved electrodes from mouth & anus to 2 temporal regions of cranium & animals survived.
*Suggest possible clinical application in 1937 1st International Psychiatric Congress in Switzerland.
*After returning, heard that pigs were killed in Rome using e. They check it out & learned shock was applied to 2 side of head briefly & only stunned pig producing convulsion. The pig was killed by cutting its throat, not by the electricity.

Front 57

ECT
The Beginning: Humans

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*Schiz male found wandering the streets.
*His condition was severe, identity unknown, prognosis poor.
*Shaved head, placed on bed & attached electrodes to temples.
*80v 1/10 sec caused brief tonic spasm throughout body but no seizure.
*Then tried 90 v at 1/10 sec. Caused slightly longer tonic spasm like first, turned pale, relaxed, took deep breath. After 1 min opened eyes, sat up, and sang a dirty song out of tune.
*Set devise to max current. This time tonic spasm followed by clonic seizure. Stopped breathing, became cyanotic. Bini counted off apnea in 5 sec intervals. @ 48 sec patient began breathing.
*After 11 treatments patient discharged in good condition but w/ continuing problems – so, not a cure for schiz

Front 58

ECT
Curare

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*In 1940 Curare used as a muscle relaxer to prevent muscle contraction
*By 1941 43% of US mental hospitals used ECT (excessively & indiscriminately @ 1st)
*By 1950s ECT is t-ment of choice for depressive disorders
*Defenders of ECT say most effective t-ment in psychiatry & prevents patients from hurting themselves

Front 59

What made metrazol shock obsolete?

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ECT
*Metrazol shock peaked in 1939 but by 1941 43% of US was using ECT

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ECT today

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*The ONLY alt still existing & widely used today. Believed to be most effective t-ment.
*Indications
*T-ment Course
*Complications

Front 61

Shock & Convulsive Therapies
Video

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*All 3 shock therapies cause convulsion
*+ result due to changes in patient's behaviors bc patients are too tired to show psych disturbances
*Its a neurological disorder bc patients are subdued or have brain damage
*No good evidence that epilepsy cannot happen @ same time as schiz

Front 62

ECT today
Indications

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*Major Depression: psych drugs are 1st choice. If dep is severe & no response to meds, is suicidal, & is psychotic then ECT is used but is a bad sign
*Acute mania: ECT occasionally used
*Psychosis: ECT occasionally used

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ECT today
Treatment Course

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*3x a week
* 6-12 total t-ments
*Maintenance ECT: 1-3 wk intervals (continuously)

Front 64

ECT today
Complications

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*Cardiovascular: hypertension, arrhythmia (can cause heart attack & bone fractures)
*Prolonged seizures & apnea
*Cognitive: orientation & memory impairment (most char of ECT, mem imp may be responsible for therapeutic effect bc affects longterm more than short term memory)

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All things considered...
NPR

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*ECT was not working
*Depression: if you leave it alone, it will go away
*One thing dr's won't do is nothing so if you don't get better they will do even more
*ECT overused & over relied on.
*The guy is a clinical counselor (psychotherapist)