PSYCHIATRIC THERAPIES

BASED ON FOUR MODELS OF

PSYCHOPATHOLOGY

Ma. Victoria Villanueva –

Briguela, MD, FPPA
 BIOLOGIC PSYCHO SOCIO BEHAVIOR
DYNAMIC CULTURAL

ETIO Brain Early P-Ch Social Learning

Relations Relations

HX S/S of Resolve Social D/O Behavior

Disease Conflict &
Strength
Ego

TX Rx, ECT Psychotx Reorg Modify

MOD Social Behavior
System
BIOLOGICAL MODEL
 I. Psychopharmacologic Agents :
1. Antipsychotics
2. Antidepressants
3. Antimanic
4. Anti anxiety
Antipsychotics
a. Typical Agents – D2 receptor antagonism

- older antipsychotics
- Typicals divided into basis of
POTENCY
 High Potency - 10mg or less
 Low Potency - 100mg more sedating
and more anticholinergic side effects than
High Potency
Biological - Antipsychotics
- High Potency cause Acute Movement
Abnormalities : Dystonia,
Akathisia,
Parkinson’s disease like Sx

- depot injection medication reduces

relapse rates by ½ to 1/3 w/ a consequent
significant reduction in hospital bed
occupancy.
Antipsychotics
TYPICAL Low Potency doses Side Effects Potential Prob
1. Chlorpromazine 500 to 1000 sedation, Tardive Dyskinesia

Anticholinergic effects Seizures

(Dry mouth, constipation urinary
retention, blurred vision)
Orthostatic Hypotension
Extrapyramidal Sx, Sexual Dysfunction

Typical High Potency

2. Haloperidol 5-20mg/d Extrapyramidal Symptoms Tardive Dysk
(dystonias, Parkinson’s disease-like w/ long term use
Sx, akathisia)
3. Fluphenazine Anticholinergic Sx NMS
Antipsychotics
2. Atypicals – Newer antipsychotics / 2nd
generation Antipsychotics / Serotonin
dopamine antagonists
- fewer movement abnormalities, and
decrease risk for TD
- effective for those who were resistant to
typical agents
- effective for tx of positive and negative
sx of schizophrenia
Biological Model - Antipsychotics
 1. Clozapine – higher affinity for the D1 and
D4 receptors than for D2.. Low incidence of EPS
due to low activity at the D2 receptor. It also has
antagonistic activity at 5HT1A, 5HT2A, 5HT2C
and 5HT3 receptors.
 Also an antagonist at alpha1 and less at alpha2
result is sedation and hypotension.
 W/ antagonism of Histamine1 adds to the
sedative effect and
 Weight gain is attributed to high affinity of
clozapine for 5HT2C receptor.
Biological - Antipsychotics
 - Clozapine is the most effective tx for pxs
w/ schizophrenia refractory to other
therapies and improves both positive and
negative symptoms.
 Those treated w/ clozapine have
greater reduction in side effects ,
disruptiveness, hospitalizations, and
readmission after discharge
Antipsychotics
- 2. Risperidone :
 high affinity for 5HT2A receptor, w/ similar
affinity to most typical antipsychotics at D2.
 Increases serum prolactin;
 w/ long acting depot formula

-3, Olanzapine :
its side effect profile is same as clozapine but
w/ higher incidence of EPS at doses above
20mg/d. Has higher affinity to D2 and 5HT2A
receptors than clozapine and lower affinity to
D1.
Antipsychotics
 Olanzapine - effective for positive and
secondary negative sx. It is also effective
maintenance tx for schizophrenia;
 4. Quetiapine – effective in acute phase
studies; less EPS, cause more dizziness, dry
mouth and sleepiness than risperidone
 5. Amisulpride – the only one w/ effects on D2
and D3 receptors; has a projected optimum
dose in the group of between 400 and 800mg/d ;
Antipsychotics
-6. Ziprasidone :
 high 5HT2A and D2 receptor blockade and
high affinity for 5HT2A; also a partial agonist at
5HT1A receptor and potent affinity to D3,
moderate affinity to D4 and exhibit weak
serotonin and noradrenergic reuptake inhibition.
.. Associated w/ greater than 30% decrease in
depressive symptoms.
 Linked to QT prolongation
Antipsychotics
-7. Aripiprazole :
 partial D2 agonist released in 2002 in USA,
has high affinity for D2 receptors, and moderate
affinity for the 5HT2A.
 A partial agonist for 5HT1A
 Produce a stabilizing effect on both the
dopaminergic and serotonergic system .
 - Has favorable safety and tolerability profile
includes low potential for EPS, weight gain,
prolactin elevation, QT prolongation and
somnolence.
Antipsychotics
 Rapid Neuroleptization : administering of
hourly IM doses of dopamine receptor
antagonist medication (e.g. haloperidol) till
marked sedation is achieved.
 Maintenance : 1st episode 1-2yrs tx
2nd episode 5 years tx
3rd episode lifetime
Biological - Antidepressants
 1. Tricyclic Antidepressants - older group,
used less often than the newer drugs, .
 significant unpleasant side effects : sedation,
anticholinergic effects ( dry mouth, constipation,
urinary hesitancy, blurred vision) and orthostatic
hypotension.
 The most serious effect is their cardiotoxicity
with a quinidine-like effect of slowing cardiac
conduction as an overdose. TCAs can be fatal.
Biological - Antidepressants
2. Monoamine Oxidase Inhibitors (MAOI) :used
less often than the newer drugs
 also cause unpleasant side effects like weight
gain and anorgasmia
 Absolute necessity for pxs on MAOI to
maintain a tyramine-free diet to avoid a
hypertensive crisis.
 Foods contain tyramine like beer, wine,
cheese , sausages – diet restriction is difficult.
 Antidepressants
 3. Selective Serotonin Reuptake
Inhibitor (SSRI) : first agents used to tx
depression; Specifically inhibit serotonin
reuptake by presynaptic neurons
 Due to safety/ low risk overdose and
well tolerated side effects ;
Antidepressants - SSRI
 Indicated : Depression,
 Obsessive-Compulsive D/O (OCD),
 Panic D/O , Eating D/O
 Premenstrual Dysphoric D/O , Chronic
Pain D/O, Paraphilias, and ADD / ADHD
 sexual side effects : decreased libido,
delayed ejaculation and trouble reaching
orgasm are common.
 It is not toxic; easy to use once a day
dosing.
Antidepressants
 depression begins to lift for most people
after 2-4 weeks, longer at continual
medication at therapeutic doses.
Vegetative symptoms improve before
mood symptoms do.
 Mirtazapine -(remeron) potent
antagonist of H1 receptors and
moderately potent antagonist of central
presynaptic a1 adrenergic receptors.
 Half life 20 to 40 hrs
Antidepressants :
 > Px with depression w/ psychotic
symptoms ::: start w/ combination of an
antipsychotic drug and an
antidepressant.
 When psychotic symptoms have
resolved the antipsychotic agent can be
stopped and antidepressant can be
continued for several more months…
Biological : Mood Stabilizers
 In Bipolar disorder, the mainstay of
pharmacotherapy : Lithium, valproate or
carbamazepine, others (gabapentin,
lamotrigine and topiramate).
 Antipsychotic agent is added when there
are psychotic symptoms
Mood Stabilizers (Antimanic)
 1. Lithium – 1st line treatment of bipolar I
 narrow therapeutic index; requires
medical screening – check BUN and
creatinine Lithium is excreted in kidneys;
serum monitoring needed
 Therapeutic index 0.6-1.2mEq/L
 Initial side effects: nausea, vomiting, ,
polyuria and diarrhea
Mood Stabilizers
 Valproic Acid : used for treatment of acute
manic episode, 1st line tx of bipolar I ;
 Dose 20-30mg/kg BW
 Therapeutic Level 50-150ug/L
 Initial dose 250mg BID
 Side effect: alopecia, GI upset, sedation,
weight gain
 Monitor liver function, CBC w/ platelets
and serum amylase every 6 months
Mood Stabilizers
 3. Carbamazepine :
 Approved for acute manic and mixed
episodes of bipolar;
 Side effect: sedation, fatigue, dizziness,
blurred vision, nausea
 Most common adverse event: nausea,
vomiting, dizziness, sedation, benign rash
 Needs baseline assessment CBC w/
platelet
Mood Stabilizers
 Drug-Drug: Carbamazepine and
Lamotrigine use concomitantly requires
double dose of lamotrigine to achieve
normal level; sudden stoppage of carba
leads to increase level of lamotrig ->
adverse event
Mood Stabilizers

 4. Lamotrigine – for maintenance tx of

bipolar disorders
 w/ incidence of rash, more common in
younger population
Biological - Anti Anxiety
 * SSRIs, TCAs and MAOI are also
effective antianxiety agents
 1. SSRI – first line tx for panic d/o, social
anxiety, OCD and PTSD
 2. TCA – side effects are numerous, but
used due to effect on insomnia or pain
 3. MAOI – used for panic d/o and social
phobia
Anti Anxiety
 4. Benzodiazepene - high potency like
alprazolam and clonazepam
 Alprazolam 1-8mg/d
 Clonazepam 1-4mg/d
 Lorazepam 2-12mg/day
 Initially tx w/ ssri is combined benzodzne
for 1-2mos
 ECT
 Also called “Shock Therapy” involves a
brief pulse of electricity to create a grand
mal therapeutic seizure.
 The seizure treats the depression not the
electricity
 Main contraindications are anesthetic like
cardiac or pulmonary compromise

ECT
 Indications for ECT
 1. Previous good outcome
 2. Medication failure
 3. Psychotic depression
 4. Contraindications to medication
 5. Severely suicidal
Psychodynamic
 Psychotherapy :
 1. Hypnosis
 2. Psychoanalytic
 a. Insight Oriented
 b. Exploratory
 c. Psychodynamic
 i. expressive ii supportive
 3. Brief Psychotherapy
Psychodynamic
 4. Interpersonal Psychotherapy
 5. Group Psychotherapy / Combined
Group and Individual Psychotherapy and
Psychodrama
Psychodynamic - Psychotherapy
 Focuses on elucidating mental processes
outside the px’s awareness leads to
symptoms and promotes emotional and
cognitive understanding
 An integration of elements of psychic
conflicts
 Less strongly recommended, use if other
tx are ineffective
Psychotherapy
 Indications :
 1. Px w/ significant suffering hence
motivated to make sacrifice for time n
financial resources
 2. genuine wish to understand oneself
 3. Can w/stand anxiety, frustration and
strong affects that emerge in analysis w/o
acting out in self-destructive manner
 4. Mature superego and intelligence of at
least average
Psychodynamic - Psychotherapy
 1. Hypnosis – altered state of
consciousness, a dissociated state and a
state of regression;
 - it is a state when one can respond to
appropriate suggestion by experiencing
altered perceptions, memory or mood
 - use in Amnestic D/o, Dissociative
Fugue
Psychodynamic - Psychotherapy
 2. Psychoanalytic Psychotherapy –
extended or long term, as long as 6mos
 a. Insight Oriented Psychotherapy
 b. Exploratory Psychotherapy
 c. Psychodynamic Psychotherapy
 i. Expressive
 ii. Supportive
Psychotherapy
 Expressive – interpretation of unc conflicts
to produce insight
 Supportive – giving advice and praise,
focus on practical coping skills to assist px
in daily living
 Analytic Setting – uses a couch, therapist
sits behind, out of view of px’s vision
 Duration – 3-6yrs or more, >4x/week, 45-
50min/ session.
Psychodynamic

 Insight Oriented(Expressive) Supportive

 meaningful obj relation severely impaired
 good impulse control poor
 Reality testing intact poor
 Tolerate frustration poor tolerance
Psychotherapy

 Analytic Process : transference,

 Countertransference, resistance
 3. Psychodrama : a group psychotherapy,
personality make-ups, interpersonal
relationship conflicts and emotional
problems are explored by means of
special dramatic mtds.
 needs most participation and greatest
ability to lead from therapist
Psychotherapy
 4. Family Therapy –focuses on altering
the interactions among family members.

 5. Couples (Marital ) Therapy – modifies

the interaction of 2 persons who are in
conflict w/ each other over a parameter or
a variety of parameters – emotional,
sexual, financial
Behavior Therapy
 1. Cognitive Behavioral THErapy (CBT)
 - highly recommended tx ; uses variety of
approaches – psychoeducation,
continuous monitoring, breathing
retraining, cognitive restructuring, and in
vivo exposure to fear cues .
 Goal = change assumptions, appraisals,
perception, cognition/ ideas, beliefs 
change in feelings &  change in bvr
Behavior Therapy
 CBT – 3 components : didactic aspects,
cognitive techniques and behavioral
techniques
 - cognitive tech – elicit automatic thoughts
(cognitive distortion), testing, identify
maladaptive assumptions
 - behavioral tech – scheduling, mastery ,
graded task,, imagery
Behavioral
 2. Biofeedback – relies on instrumentation
to measure moment to moment feedback
about physiological processes like
measures of bp, temp, heart rate, etc
 Methods: instrumentation, relaxation,
later adaptation of progressive muscle
relaxation, autogenic training & applied
tension
Behavior Therapy

 Other Techniques :
 1. systematic desensitization
 2. therapeutic graded exposure
 3. flooding
 4. participant modeling
 5. exposure to stimuli in virtual reality
 6. assertiveness training
 7. aversive training
Behavior Therapy
 1. Systematic Desensitization based on
principle of counterconditioning ;
 A person overcomes anxiety elicited by a
situation or an obj by approaching feared
situation gradually in psychophysiological
state that inhibits anxiety.
 > Steps used: relaxation, hierarchy
construction and desensitization of
stimulus
Behavior Therapy

 > relaxation produced physiological

effects opposite to those of anxiety –
slows HR, neuromuscular stability
 > mental imagery pxs are instructed to
imagine themselves in a place assoc’d w/
pleasant relaxed memories
Behavior Therapy
 > hierarchy construction – list of items
in order of increasing anxiety ex. Px
imagines stand’g near a window of 2F and
ends being on a roof of 20 story bldg
 > desensitization of stimulus –px
proceed systematically using list fr the
least to most anxiety provoking scenes
while in deep relaxed state.
Behavior Therapy
 2. Therapeutic Graded Exposure – like
systematic desen., no relaxation training
involved.
 3. Flooding –(Implosion) like in Graded
Exposure, involves exposing the px to
feared object in vivo, has no hierarchy and
no relaxation used.
Behavior Therapy
 4. Participant Modeling – new behavior is
learned by imitation primarily by
observation w/o having to perform until
they feel ready.
 5. Assertiveness Training – confidence in
judgment, sufficient self-esteem ; role
modelling.
Behavior Therapy
 6. Aversion Technique – a noxious
stimulus is presented immediately after a
specific behavioral response
 - electric shock , substance induced
vomiting
 Positive Reinforcement – behavior
response is followed by a generally
rewarding event like food., praise.

Behavior Therapy
 - easily taught
 - less time than other therapies
 - less expensive to administer
Sociocultural
 TX = Reorganizing patient’s relation to the
social system i.e. restructure the nuclear
social system thru marital/ couples &
family Tx, environmental manipulation,
 Family intervention, Patient Education,
Medication Compliance Therapy
 TX = Reorganizing social system e.g.
advocacy for adequate housing &
education, Assertive community Tx
Sociocultural
 Family Intervention – reduces level of
negative expressed emotion – anger, guilt,
sad
 Patient Education – px engage in beh
change, prevents hosp, manage illness n
get maximum degree of health
 Medication Compliance Therapy – for px
that stop meds
 SOCIOCULTURAL MODEL
 TX
 Couple/ Marital, Family Tx
 Milieu Tx- Provide substitute or transitional social
support ; 24-hr day prog in community
 Social Skills Trng- Acquire social skills to maintain
relationships; role play
 Environmental Manipulation = Move residence to be
nearer family & friends
 Vocational Trng -Encourage returning to work;
 Self- Help Programs
 Group Psycho – immediate feedback fr
peers; chance to observe px’s responses
to others
 Self-help Grp – pxs coping w/ specific
prob organized and educate each other;
cohesion.
BIOPSYCHOSOCIAL MODEL
 MULTIMODAL TX
 ECT, Rx
 Psychotx
 Environmental Manipulation, Social
Support
 Behavioral & / or Cognitive Tx
 BIOLOGICAL PSYCHODYNAMIC SOCIOCULTURAL BEHAVIORAL

ETIO Brain Early P-Ch Social Learning

Relations Relations

HX S/S of Resolving Social Behavior

Disease Conflict & Disorder
Strengthen
Ego

TX Rx PsychotX Reorg Modify

Social Behavior
System
Thank you
QUIZ:Give Model of Psychopathology where the Psychiatric
Treatment Belong.
 Biological, Behavioral, Psychodynamic, Sociocultural
 1. Systematic desensitization
 2. Clozapine
 3. Environmental manipulation is a treatment mode
used by patient.
 4. Quetiapine
 5. ECT
 6 Biofeedback
 7. Family Intervention
 8. Psychoanalytic PSychotherapy
 9. Patient Education
 10. Role modeling for phobic children.