alternatives-psyc 4039 (exam 3) – Flashcards

something other than analysis and warehousing

covers somatic therapies between circa 1900 and 1950

-was therapeutic, the first was not -change from from anatomical studies to somatic therapies -by 1900, disillusionment about treatment, especially of serious mental illness -the therapies here are outgrowth of attempts to restore a therapeutic mission to psychiatry, particularly in the hospital

-custodial institutionalization -psychoanalytic psychotherapy

-shock therapy (ELECTRICAL STIMULATION) -hydrotherapy -faradization -pharmacotherapy

deep sleep therapy and prolonged hibernation

therapeutic power

decrease in recovery rate, thousands of patients, mirror of desolation, cleaner than before, higher discharge rates of adolescents

Flemish physician Dr. Jan Baptista van Helmont

-ALKALOIDS (derived from plants): ---morphine ---hashish ---cocaine ---Belladonna Alkoloids (atropine, scopalamine) -SYNTHETICS (man-made): ---chloral hydrate ---paraldehyde ---bromides

-a purgative used to empty out the GI track -a precursor to alkaloids and synthetics

-USED FOR NARCOANALYSIS -synthesized in 1832 -introduced into medicine in 1869.has been used for NARCOANALYSIS. colorless, slight bitter taste -aromatic odor. liquid chloral called knock-out drops -Mickey Finn, liquid chloral added to alcohol. -combination of chloral and alcohol has very potent hypnotic effects

-A MIXTURE OF CHLORAL AND ALCOHOL -WOULD KNOCK OUT PATIENTS LIKE A ROOFIE NAMED AFTER A BARTENDER

discovered in 1829 introduced into medicine in 1882 -less potent and less toxic than chloral

-USED IN EPILEPSY TREATMENT -discovered in 1826 -introduced as depressant for treatment of epilepsy in 1857 -produces lighter sleep than with chloral and paraldehyde -may cause hangover -low acute toxicity -chronic toxicity frequent (called bromism) -first used in prolonged sleep therapy in 1897 by Macleod

-malaria therapy -defocalization (surgical antisepsis) -insulin-coma therapy -Metrazol convulsive therapy -electroconvulsive therapy -psychosurgery -electrical brain stimulation -pharmacotherapy

-breaking therapeutic nihilism -Julius Wagner von Juaregg (1857-1940)

MALARIA THERAPY

-born in Austria -graduated in medicine in 1880 in Vienna -"dyed in the wool" anti-Semite (common among Austrians -did his residency in psychiatry in the Vienna Asylum

-Juaregg notes improvement in psychotic woman who has a strep infection in 1883 -Juaregg proposed that fever could be therapeutic in psychosis and paresis in 1887 -in 1890s he begins tuberculin therapy -received the Nobel in 1927 -INJECTED BLOOD INTO PATIENTS WITH NEUROSYPHILIS-SAW DECREASE IN SYMPTOMS

-FEVER THERAPY -fever was the proposed mechanism because the syphilis spirochetes are heat sensitive -tuberculin=derived from cultures of tuberculosis bacteria. Used for a while as a TB vaccine. but ineffective and dangerous. still used to detect TB. stopped using tuberculin because it is toxic -tried malaria because the infection could be controlled with quinine. -A soldier (and former patient of Juaregg) came from front with shell shock and malaria. He infected his blood into patients with neurosyphilis. a year later reported results in 9 patients. fever therapy restored patients to near normal lives. only medical therapy for a mental disorder at the time. Hospital had to keep strains of malaria in hospital. Malaria in GPI patients was only terminated after it has been successfully transmitted -penicillin discovered in 1929 by Alexander Fleming. took a decade before it became widely available. makes fever therapy obsolete. -malaria therapy a watershed event to medicine and psychiatry -broke the therapeutic nihilism that had dominated psychiatry and increased optimism that treatments for other psychiatric disorders could be found -fever therapy tried in all other psychiatric conditions without success

-WAS EFFECTIVE FOR SYPHILIS PARESIS -USED TO TREAT GENERAL PARESIS OF THE INSANE/ADVANCED SYPHILIS -EFFECTIVE IN GPI PATIENTS BECAUSE FEVER KILED THE SYPHILIS BACTERIA -PENICILLIN MAKES MALARIA THERAPY OBSOLETE IN 1940S -SEEMED TO ONLY WORK IN SMALL SPECIFIC GROUPS OF PATIENTS

focal infection theory and defocalization

DEFOCALIZATION -ALSO KNOWN AS SURGICAL ANTISEPSIS

-BELIEVED MENTAL ILLNESS WAS AN INFECTION IN THE BODY IN A RANDOM PLACE, MAINLY ROTTON TEETH, AND TOXINS TRAVELED TO BRAIN CAUSING MENTAL ILLESS -IF SOMETHING WAS REMOVED AND NO CURE, HE ASSUMED INFECTION WAS ELSEWHERE ADN REMOVED OTHER BODY PARTS -LED TO WIDE SCALE TEETH REMOVAL IN MENTAL PATIENTS -REPORTED 80% RECOVERY RATE -SKEPTICISM OF THIS LED TO FIRST CONTROLLED STUDY IN PSYCHIATRY IN 1920S PROVING IT DID NOT WORK -TECHNIQUE DIED WITH COTTON

treatment of mental illness by surgical removal of infected tissue or organ: -infected teeth -infected tonsils -infected colon

diagnosis: problem is many infections were hidden. any sign of disease (e.g. swelling or lesion) or presence of bacteria taken as sign of infection -treated 1000 patients surgically -reported an 80% recovery rate -controlled studies showed no more infections in psychiatric patients compared to controls and no greater improvement following surgery

Manfred Joshua Sakel (1900-1957)

-insulin is a protein hormone secreted by the pancreas that causes tissues to take up glucose. In doing so, it causes hypoglycemia. deprive the brain of glucose leading to seizures and coma. -use of toxic doses of insulin to induce coma then leaving them for 1-2 hours

discovered by Banting and Best in 1921. in 1923 Banting got Nobel Prize

INSULIN COMA THERAPY

born in 1900 in Austria into a pious Jewish family -graduated in medicine in 1925 University of Vienna -because of strong antisemitism went to Berlin as physician in an expensive private clinic- Lichtervelde Sanatorium-that catered to wealthy drug addicts -in 1933 he returned to Vienna -in 1936 he emigrates to US -a sad figure/not liked/quick tempered/arrogant/dogmatic -felt he was not given credit for his discovery of insulin coma therapy and in trying to convince others of his greatness manage to alienate nearly everyone

in 1930 Sakel reports insulin useful in treating drug addiction and psychosis -in 1935 he reports 88% success rate in use of deep coma therapy to treat schizophrenia -insulin units established in hospitals throughout the US and Europe by 1940

-different accounts of how it was discovered: -according to one (Valensteine) accidental overdose in diabetic mental (drug addicted) patient -another, (Thriller) insulin had been used to stimulate appetite in depressed and anorectic patients and Sakel tried it in psychotic patients on a hunch to see what would happen. According to Sakel, it came about as a result of rational scientific reasoning. He was looking for a way to suppress excitation in morphine withdrawal. He attributed this to endocrine and sympathetic excitation and he hypothesized that insulin would antagonize these physiologic responses. According to Shorter, in treating morphine withdrawal, he noticed that it decreased desire for drug and calmed agitated states. For whatever reason, he began using insulin circa 1938. -success rate-full remission in 70%, "social remission" in 18% -by 1960 there were over 100 insulin units in US hospitals

-entire wards were given over to insulin coma therapy-a labor intensive and dangerous therapy -a coma ward might have as many as 30 patients in various stages of insulin therapy at a time -these patients would likely be restrained to the bed -nursing was very important-at least one for every 2 patients constantly present -beside each bed would be bottles of glucose syrup, sweetened orange juice, ampules, and syringes -treatment was begun early in the morning with an injection of insulin in the gluteus maximus -does was dependent on stage of treatment; typically started with low doses and increased them -shortly after injection, the patient becomes quiet as the brain is deprived of glucose -some patients perspired and drool copiously -respiration and heart rate increase -within an hour those that receive high enough doses lapse into a coma -irregular muscle contractions begin -patient may slowly move head from left to right; hand and wrists twitch; arm may extend suddenly reaching straight up into the air; patient sucking motion of lips resembling a nursing infant -such "primitive movements" were thought to result from a freeing up of lower brain centers from control of the grey matter of the cortex which is inhibited by the insulin -with high doses some patients have violent seizures -serious judgment was how long to maintain the coma -too short and it wouldn't work, too long and patient might not be revived or suffer brain damage -typically deep coma maintain 1-2 hours then given a glucose drink by mouth or intubation -COMPLICATION: BRAIN DAMAGE -HAD HIGHER DEATH RATES THAN ECT AND METRAZOL

-1929 Meduna proposes biologic antagonism between epilepsy and schizophrenia -1935, metrazol-convulsive therapy begun -MEDUNA USED CAMPHOR AND EVENTUALLY METRAZOL TO INDUCE SEIZURES IN PSYCHOTIC PATIENTS

Austrian, circa 1750, used camphor to produce seizures and treat what we would call bipolar disorder today -his work was forgotten -Meduna rediscovered therapy

METRAZOL CONVULSIVE THERAPY -INDUCE SEIZURES USING METRAZOL

-rediscovered therapy -compared brain on autopsy of epileptic and schizophrenic patients and thought they were different -then other researchers reported the epileptics who became schizophrenic experience less severe epilepsy. -proposed the two diseases were antagonistic -in 1934, he used camphor to induce a seizure in psychotic man -by 1935 he had treated 26 patients, many showed dramatic improvement -problems with camphor: unreliable in producing seizures, anxiety, and pain when injected -1935, he changed to the cardiac stimulant metrazol (Cardiazol) -between 1935 and 1940, many hospitals experiment with metrazol units -it never really caught on because the seizures were so severe -MADE OBSOLETE BY ECT (ELECTROCONVULSIVE THERAPY)

-developed by Cerletti in collaboration with Lucio Bini by animal experiments

DEVELOPED ECT

-(1877-1963) -Director Clinic for Mental and Nervous Diseases in Rome -interested in animal models for epilepsy -experimented with metrazol shock -1933, developed a model of epilepsy in dogs using electric shock -half of dogs died because of electrode placement -1938, first clinical trial of ECT (on schizophrenic man-left in good condition but not a cure for schizophrenia)

ELECTRICAL PULSE DELIVERED THROUGH BRAIN TO CREATE A SEIZURE -WIDELY ADOPTED BY US MENTAL HOSPITALS -TREATMENT OF CHOICE FOR DEPRESSIVE DISORDERS

-experimented with Cardiazol convulsive therapy -didnt like it because "consciousness is not lost immediately, and it is preceded by a sensation of asphyxia which is agonizing for the patient" -because of his experience with electrically induced seizures he considered applying this methods to patients, but was concered about safety -about half of the dogs in their experiments died from cardiac arrest -moved electrodes from mouth and anus to two temporal regions of cranium and animals survived -suggested possible clinical application in 1937 in the 1st International Psychiatric Congress in Switzerland -after returning, they heard that pigs were killed at a slaughter house in Rome using electricity-this gave them pause -They checked it out and learned that shock was applied to two side of head briefly and only stunned the pig producing a convulsion-the pig was killed by cutting its throat not by the electricity -convinced of the safety they did the first trial in a human-patient was a schizophrenic male found wandering the streets several weeks previously -his condition was severe, identity unknown, prognosis poor -shaved head, placed him on bed and attached electrodes to temples -80v 1/10 sec caused brief tonic spasm throughout body and no seizure -then tried 90v at 1/10 sec--caused slightly longer tonic spasm like first, turned pale, relaxed, took deep breath -after 1 minute opened his eyes, sat up, and sang a dirt song out of tune -set devise to maximum current -this time tonic spasm followed by clonic seizure -stopped breathing, became cyatonic. -Bini counted off apnea in 5 sec intervals -at 48 seconds patient began breathing -after 11 treatments patient discharged in good condition but with continuing problems-so not a cure for schizophrenia

complication-metrazol and ECT=fractures and dislocations; insulin=brain damage

-1940 Curare (PARALYTIC AGENT) used to prevent muscle contraptions (JUST HID SIGNS OF SEIZURE) -(PATIENT HAD TO VENTILATED WITH CURARE BECAUSE IT PARALYZES THE MUSCLES OF DIAPHRAGM-MUST BE ASSISTED WITH BREATHING) -by 1941 43% of US mental hospitals used ECT -ECT excessively and indiscriminately at first -by 1950s ECT is treatment of choice for depressive disorders

ECT rapidly pushed metrazol shock into obsolescence -metrazol peaks in 1939 -by 1941, 43% of US mental hospitals were using ECT

-USED MOSTLY FOR MAJOR DEPRESSION EVEN TODAY -acute mania -psychosis

-three times per week (OFTEN) -6-12 total treatments -maintenance ECT: 1-3 week intervals

-cardiovascular:hypertension, arrhythmias -prolonged seizures and apnea -cognitive: disorientation and MEMORY IMPAIRMENT (TO MINIMIZE/ PREVENT MEMORY LOSS (ALTHOUGH SOME THINK IT IS HELPFUL IN RECOVERY) THEY WOULD HAVE PATIENT HYPERVENTILATE BEFORE SHOCK TREATMENT)

MOST WIDELY USED OF ALL ALTERNATIVES TODAY FOR MAJOR DEPRESSION BUT CAN BE USED IN SOME WAY FOR JUST ABOUT ANYTHING

-THERAPY USING DRUGS AFTER 1900 -1900-1950 -stimulants (amphetamine)- (AVAILABLE IN 1930-TREATS DEPRESSION) -antihistamines (1930S-USED FOR SEDATION AND LED TO FIRST ANTIPSYCHOTIC) -LSD (and other hallucinogens)- (USED ON PSYCHOTIC PATIENTS FOR A SHORT TIME) -barbiturates (barbital: Veronal & Medinal)- (POWERFUL SEDATIVES)

Veronal & Medinal

FIRST BARBITURATE

-prolonged narcosis -depatterning -narcoanalysis

DISCOVERED IN 1903 BY FISHER AND MERING- USED WIDELY AS SEDATIVES)

deep sleep therapy

DEEP SLEEP THERAPY (PROLONGED NARCOSIS) -DISCOVERED DEEP SLEEP THERAPY ACCIDENTALLY WITH BROMIDE -USED BROMIDE TO TRANSPORT WOMAN FROM JAPAN TO SHANGHAI- SHE RECOVERED) -DIDNT USE BARBITURATES

FIRST BIOLOGIC TREATMENT THAT WAS EFFECTIVE IN TREATING MENTAL ILLNESS-SODIUM BROMIDE)

-Macleod -Klaesi -Baily -Sargant

POPULARIZED BARBITURATES

HAD A COMPETITION SEPARATELY ON WHO COULD MADE A PATIENT SLEEP LONGER AND KILLED MANY PATIENTS

CHARGED FOR KILLING DOZENS OF PATIENTS WITH PROLONGED NARCOSIS/ OVERUSED BARBITURATES

DEPATTERNING -DEPATTERNING INVOLVING PROLONGED SLEEP WITH ECT AND PLAYING AUDIO MESSAGES IN PATIENTS ROOM WHILE THEY SLEPT TO REPLACE MEMORIES

Cameron -BREAK UP PATTERNS OF THINKING

-first somatic therapy of 20th century -started by Macleod in 1897 with bromide -used to transport disturbed woman from Japan to Shanghai -afterward, tried on other patients too -deep sleep induced for 5-9 days -patients put on toilet every few hours and given milk

-discovered in 1903 by Fisher and Mering -widely used as sedatives -main advantage higher therapeutic index -also for prolonged sleep -popularized by Swiss psychiatrist Jacob Klaesi in 1920s for treating schizophrenia -high mortality ca 5%

SLEEP THERAPY

-Swiss psychiatrist -popularized bariturates in 1920s for treating schizophrenia BY PROLONGED NARCOSIS -USED BARBITAL FOR SLEEP THERAPY -he later used safer drugs and treated mood disorders and withdrawal from heroin -only treatment available and widely used in early 30s

-combining prolonged narcosis with "psychic driving" or "brain washing" (listening to propagandistic messages) and ECT -done by Cameron in 1950

-a conduct of psychoanalysis (a particular psychotherapy) in patients treated with sub hypnotic doses of sedatives such as thiopental (ultra short acting) or amobarbital (Amytal; intermediate acting 6-8 hours) -based on belief that drug produces disinhibition resulting in confession and expression of repressed memories (psychotherapy) -USED BARBITAL TO SEDATE THEN TALK TO PATIENTS

derived from observations of patients given methamphetamine to treat barbiturate overdose -produces euphoria, excitement, talkativeness, etc.

-HAD SEDATIVE ACTIONS -THORAZINE DEVELOPED FROM ANTIHISTAMINES

TREAT DEPRESSION