Pharmacology and Cognitive Behaviour Therapy - Essay Example

Comparison Of Two Psychiatric Interventions: Pharmacology And Cognitive Behaviour Therapy Cleo is a 21 year old Caucasian female who was diagnosed with schizophrenia when was in adolescence. Currently, she is in a forensic unit because she became violent and attacked a neighbour. Because she has a proven "mental disorder" it was found that she should go to a psychiatric facility instead of jail. The hope was that during her confinement she would receive treatment and rehabilitation. This is not the first time in a psychiatric using for her behaviour. She has been admitted as an adolescent because she was threatening and aggressive to her community. Two weeks prior to the current incident, Cleo lowered her dosage of medication (she lives with her family and they encouraged her to alter her medication). This action led to a "decompensation" of her mental state which the doctors think could have been a contributing factor to her most recent episode. It should be noted that Cleo has a "significant history" of non-compliance with treatment and medication regiments. Cleos family, though they are supportive, do not understand the extent of Cleos mental health. Although Cleo talks about her family a lot, she also believes them to be involved with the Nazis and she must protect them; hence the reason why she does not want to be in the hospital. During her current hospital stay, she became violent and suspicious with staff. Her behaviour is always unpredictable: She can be talking nicely to staff one minute and then jump across the counter to hurt someone in the next minute. She is also sexually promiscuous with other patients and she takes things form them. Other behaviour that she has exhibited include burning her hair, shaving her head (to be in fashion), and later cutting herself and licking the wound to "cleanse her spirit" (Case Study, p. 38). Through Cleos promiscuous behaviour she has contracted a sexually transmitted disease. She was caught having sex with one patient and trying to seduce another. Although the hospitals has a policy that allows patients to have sex, staff questions whether Cleo can actually give consent for sex. After talking to her family about it, they are split as to how they feel. Part of them feel she has a right to have sex with anyone she wants, and the other part of the family thinks that the other patients may take advantage of her. Unsafe Work Environment Cleos behaviour has created safety issues for everyone on the Ward. Many employees want to move to another area and others want Cleo to be moved. There have been increased absences and requests for workplace safety and Insurance Board claims. Cleo has been actively violent against some, racist towards others and generally disruptive on the Ward. When addressing this with her family, the family feels that since she is on a forensic unit, they should be able to deal with her. DIAGNOSIS OF CLEO There are several issues with Cleo that come to mind as her case is examined. The greatest challenge for her seems to be that her behaviour is not under control. She was diagnosed with schizophrenia and on the ward she is getting medicine "PRN" which does not seem to be working for her. According to ODonahue and Levensky (2004), Cleo had to be very disturbed during her trial in order to get the insanity defence. According to them, only 54% of those who are diagnosed with schizophrenia receive the insanity sentence because it has to be proven that the individuals disorder is causing the impairments (p. 160). In Cleos case, this is a direct result of not taking her medication properly. Although the case study says that her "strength" is that she lives with her family, she has a positive relationship with them and she talks about them extensively, this seems more like a trigger than a strength. Since much of her hallucinations are dealing with her familys involvement with the Nazis, they do not seem to be a positive influence on her and they obviously cannot help her control her problems. She is also sexually promiscuous with abandon as it seems, and no one seems to know quite what to do about it. There are many case studies and journal articles about what to do in these situations and it seems that the staff should be reading them. As an example, Hughes and Hebb (2005) suggest that "inappropriate" sexual behaviour should be addressed right away, especially in a setting such as this (p. 97). They also suggest that staff should be trained in this area. In this therapists opinion, Cleo should stay at the forensic unit or some other community psychiatric hospital until she is able to take her medication regularly or until she is stabilized. The challenge is that Cleo may never be motivated to take her medication properly because of the attention she receives without it. A question does come to mind about her mood swings on the ward. It would seem that she is being given medication but it may not be enough, or she is being given pills and she is only pretending to take them. THERAPY APPROACHES The approaches that I have chosen for Cleo include pharmacology and cognitive behaviour therapy. I would have this treatment done in a psychiatric facility until she was stabilized and then see if this could be moved to a community health facility. I believe that Cleo will always have to be monitored for her medication. Pharmacology The standard for treating schizophrenia has always been to use some form of pharmacology. Experts different on the type of medication to use because many studies have shown that a variety of medications do not work for this illness. Usher and Luck (2004) studied acute psychotic behaviour and found that people could respond to "prn" medication whether the medication was antipsychotic or benzodiazepines. In Cleos case, I would suggest that an intra-muscular injection be given so that staff was sure that she was taking her meds and because this is faster acting. A challenge may be that she is resistant to taking the medication which means she may struggle. Although the case study says she is already getting prn medication, it does not mention how much, how often or when; this would need to be described. Usher and Luck suggest that the atypical antipsychotics may be a better fit for some (for Cleo too) because they do not have the side effects that traditional antipsychotics do. According to their study, a combination of antipsychotics and benzodiapines are better than using one or the other. It may be that Cleo is only receiving one type of medication or that she needs a new medical workup to change her medication. The combination of drugs in this case would help with her aggression and/or psychotic symptoms (Usher and Luck, p. 20). Also, some experts suggest that a benzodiazepine should be the "first line of action" in acute psychotic cases (Usher and Luck, p. 20). Miyamoto, Duncan, Marx and Liebermann (2005) also suggest that the newer antipsychotics are better in treating schizophrenia because they have "greater improvement in negative symptoms, cognitive impairment, relapse prevention, functional capacity and a quality of life …" (p. 79). They suggest that the serotonin-dopamine antagonisms theory is important to consider because it says that those drugs high in serotonin may "predict antipsychotic efficacy" (p. 82). Gray and Roth (2007) explored the future of drug therapy because they were concerned with what researchers were finding that showed promise in helping schizophrenia. Many new drugs are working with the natural chemicals and other substances that the body naturally produces. As an example, various neurotransmitter receptor agents are "extremely valuable" in understanding brain physiology and the pathophysiology of disorders like schizophrenia (p. 916). Other research is being done on the neural network or looking at molecular genetics. As scientists continue to see schizophrenia as a "neurodevelopmental disorder" they are looking into natural ways to inhibit the brain to stop psychotic behaviour. Since Cleo seems to be an extreme case, some of the newer ways of dealing with schizophrenia may be better help to her in the future. Frankle (2007) reported on neuroreceptor imaging for schizophrenia. This technique "allows for the in vivo study of specific molecular brain functions in psychiatric illnesses" (p. 212). Because subtle brain abnormalities were found in people with psychiatric illnesses after they died, the neuroreceptor imaging will allow scientists to study the brain of schizophrenics before they die to find these abnormalities. This is a way that scientists are able to see the real effects of dopamine and other receptors. Again, it would be important for clinicians working with Cleo to keep abreast of the newer pharmacological methods. These newer methods may help in the event that other medications are not working for her. Many studies show that these newer drugs are best. Roth, Sheffler and Kroeze (2004) suggest that "non-selective" drugs are better for schizophrenia than other types of drugs because the "selective" drugs have not worked (p. 353). They also suggest that certain non-selective antidepressants like dopamine and noradrenalin work well because of their dual action abilities (p. 357). These researchers add weight to the fact that the traditional medications do not work as well. Nettestad and Linalar (2003) studied psychotropic drugs with people with "intellectual disabilities" which included schizophrenia. Their study was done with residents of a particular institution who were between the ages of 15 and 67. The interesting part was that they studied the effects of the drugs once the individuals were released. They found that these traditional drugs were not effective for intellectual disabilities. Pharmacology is a very important aspect of treatment for schizophrenia but it needs to be combined with therapy. In Cleos case, it seems that in the beginning stages of her treatment, most of the focus was on attempting to stop her violent behaviour. She was getting "prn" medication, but this does not seem to be working for her. It is clear that she should have a full medical workup to determine the correct type of medication, its dosage and how it should be given to her. The atypical medications should be used since evidences shows they are more effective in treating schizophrenia. COGNITIVE BEHAVIOUR THERAPY (CBT) In a majority of mental illnesses that work with mood disorders, the combination of pharmacology and CBT is used. Christodoulides, Dudley, Brown, Turkington and Beck (2008) studied cases of patients who were not on antipsychotic medication, but who were experiencing CBT. They studied this group because they wanted to se whether CBT would work as well as antipsychotic medication since many schizophrenic patients tend not to take their medication (p. 200). They studied nine cases and found that "CBT for psychosis, in the absence of antipsychotic medication, is feasible and can be a helpful intervention for some in reducing positive symptoms of schizophrenia" (p. 204). McGovern and Tarkington (2001) also studied CBT as a viable treatment approach. They chose CBT because of its success with depression and anxiety. They presented a continuum model that emphasized the "similarities across disorders." The example they gave was the fact that CBT has been used to treat depression and anxiety so it could be used to treat these two factors in schizophrenia; it could also be used to change the dysfunctional thinking that is part of the disease. Naeem, Kingdon and Turkington (2006) support McGovern and Turkingtons research. They indicate that "approximately 50% of patients improve, even when treatment symptoms are resistant" (p. 153). They looked at anxiety and depression and explained that many people with schizophrenia experience anxiety symptoms as their response to psychotic symptoms (p. 154). The study found that anxiety was helped through CBT. Some schizophrenic patients experience high level anxiety and when they do, this often causes a relapse for them. These researchers suggest that more study should be done in this area. In a different study, Naeem, Kingdon and Turkington (2008) continued their research and found that there was enough evidence to support CBT for psychotic symptoms. They found that they could predict whether someone was a good candidate for CBT by looking at the severity of their illness. Within this process they found that those patients who were aware of their symptoms were more likely to accept therapy. Their awareness or "good insight" was also a predictor for whether an individual would respond well to CBT (p. 655). THE IMPACT OF INTERVENTIONS ON CLEO Taylor, Chaudry, Cross et al (2005) suggest that long-term management for schizophrenia should include clear strategies for treatment goals. They also suggest that it is important to look at the clients total well-being in order to look at various situations that may cause relapse (p. 177). Treatment plans should also include psychosocial interventions. In Cleos case, this therapist would think that it is important for Cleo to have some sort of psychosocial intervention so that she understands the value of other people. To date, she does not seem to value anyone, including herself. In the forensic setting, there are problems for Cleo because this unit is pretty straightforward in the way that patients are treated and in the behaviour that is expected. Staff has to take more time with her than is fair to the other patients and they are not exactly sure what to do with her. Privacy is a challenge on a forensic unit and patients have to leave behind what they know at home to accept the changes in the psychiatric unit. They also have to go into an environment that is unfamiliar which often means they lose any social situations they have maintained. With Cleo a combination of CBT and pharmacology is indicated because she needs to understand boundaries and that she cannot strike people because she feels like it. Her family is not helpful to her though under normal circumstances, a family should be able to help with medication and with de-escalating a situation once they have had training. The community in this case does not have a real role because Cleo is not ready to work within the community yet. She may be able to learn how to do as she progresses. The role of the therapist is to help her realize her goals and to help her through the process. Ethical considerations for Cleos case would start with the type of medication she received. It would be important to know whether she can be forced to take an intramuscular injection rather than pills if she is not taking her pills. The situation for her around sexuality would also have to be explored because her rights and the rights of other patients would have an ethical base. The fact that she is violent on the ward must be addressed and ethical solutions to her behaviour must be explored. As an example, does she have to remain in restraints when she acts out in this way or is there other things that can be done? It seems that the employees on the ward are not addressing the issues; instead, they are looking for ways out of the ward. I would think that a combination of CBT and atypical medications would be the most useful for Cleo. There is no one right answer to this so the doctors would have to work with her medication to obtain the right dosage. The therapist would need to help Cleo define her goals and stick to them. It is difficult to tell however, whether Cleo would be a good candidate as someone who can actually improve and be rehabilitated. Cleo may benefit from a training that Hodel and West (2003) presented called In VIVO that is done in groups. The training is 20 sessions, 45 minutes twice a week for ten weeks. They used behavioural techniques that included "modelling, role-place, in vivo training and homework assignments" (p. 556). This could be something to add to Cleos treatment plan to help her understand and accept psychosocial situations. References Christodoulides, T., Dudley, R., Brown, S., Trakington, D., and Beck, A. (2008). Cognitive behaviour therapy in patients with schizophrenia who are not prescribed antipsychotic medication: A case series. Psychology and Psychotherapy: Theory, Research, and Practice. 81(2). p. 199-207. Retrieved October 21, 2009 from Academic Search Premier. AN: 32930644. Frankle, G.W. (2007). Neuroreceptor imaging studies in schizophrenia. Harvard Review of Psychiatry. 15(5). p. 212-232. Retrieved October 20, 2009 from Academic Search Premier. AN: 26952090. Gray, J., and Roth, B. (2007). The pipeline and future of drug development in schizophrenia. Molecular Psychiatry. 12(10), p. 904-922. Retrieved October 21, 2009 from Academic Search Premier. AN: 26854940. Hodel, B., and West, A. (2003). A cognitive training for mentally ill offenders with treatment-resistant schizophrenia. Journal of Forensics Psychiatry and Psychology. 14(3). p. 554-568. Retrieved October 20, 2009 from psycINFO AN: 2003-10588-006. Hughes, G.V., and Hebb, J. (2005). Problematic sexual behaviour in a secure psychiatric setting: Challenges and developing solutions. Journal of Sexual Aggression. 11(1). p. 95-102. McGovern, J., and Turkington, D. (2001). Seeing the wood from the trees: A continuum model of psychopathology advocating cognitive behaviour therapy for schizophrenia. Clinical Psychology and Psychotherapy. 8(3). p. 149-175. Retrieved October 21, 2009 from Academic Search Premier. AN: 11820362. Miyamoto, S., Duncan, G., Marx, C. and Liebermann, L. (2005). Treatments for schizophrenia: A critical review of pharmacology and mechanisms of action of antipsychotic drugs. Molecular Psychiatry. 10(1), p. 79-104. Retrieved October 20, 2009 from Academic Search Premier. AN: 15495311. Naeem, F., Kingdon, D., and Turkington, D. (2006). Cognitive behaviour therapy for schizophrenia: Relationship between anxiety symptoms and therapy. Psychology and Psychotherapy: Theory,Research and Practice. 79(2), p. 153-164. Retrieved October 21,2009 from Academic Search Premier. AN: 21148174. Naeem, F., Kingdon, D., and Turkington, D. (2008). Predictors of response to cognitive behaviour therapy in the treatment of schizophrenia: A comparison of brief and standard interventions. Cognitive Therapy and Research. 32(5). p. 651-656. Retrieved October 21, 2009 from Academic Search Premier. AN: 34476893. Nottestad, J.A., And Linaker, O.M. (2003). Psychotropic drug use among people with intellectual disability before and after deinstitutionalization. Journal of Intellectual Disability Research. 47(6). p. 464-471. Retrieved October 21, 2009 from psycINFO AN: 2003-07270-007. ODonahue, W., and Levensky, E. (eds.). (2004). Handbook of forensic psychology: Resource for mental health and legal professionals. NY: Elsevier Academic Press. Roth, B.L., Sheffler, D.J. and Kroeze, W.K. (2004). Opinion: Magic shotguns versus magic bullets: Selective non-selective drugs for mood disorders and schizophrenia. Nature Reviews Drug Discover. 3(4). p. 353-359. Retrieved October 20, 2009 from Academic Search Premier. AN: 12728646. Taylor, M., Chaudry, I., Cross, M., McDonald, E., Miller, P., Pilowsky, L., and Strickland, P. (2005). Towards consensus in the long-term management of relapse prevention in schizophrenia. Human Psychopharmacology: Clinical & Experimental. 20(3). p. 175-181. Retrieved October 21, 2009 from Academic Search Premier. AN: 16658282. Usher, K., and Luck, L. (2004). Psychotropic PRN: A model for best practice management of acute psychotic behavioural disturbance in inpatient psychiatric settings. International Journal of Mental Health Nursing. 13. p. 18-21. Read More