39 THE SCIENTIF ℃ METHOD The solution to this problem is simple. Just as the patients should not know whether they are receiving a drug or a placebo, neither should the experimenter. Someone else should administer the pill, or the ex- perimenter should be given a set ofidentical-looking pills in coded containers, SO that bOth experimenter and patient are unaware Ofthe nature Ofthe contents. Now the ratings cannot be affected by experimenter bias. We call this method the double-blind proce- dure. The double-blind procedure does れ ot apply only tO expenments that use drugs as the independent variable. Suppose that the experiment ljust described attempted tO evaluate the effects Of a particular kind of psychotherapy, not a drug, on the ability of a therapist tO commumcate with a patient. ()n fact, we will encounter such evaluations in Chapter 18. ) If the same person did both the psychotherapy and the ratmg, that person might tend tO see the results in a light that was most favorable tO his or her OW れ ex- pectations. ln this case, then, one person should per- form the psychotherapy and another person should evaluate the quality Of conversatlon with the pa- tlents. The evaluator will not know whether a partic- ular patient has Just received psychotherapy or IS a member of the control (untreated) group ・ receive amphetamme, and those in the Other group will recelve an mert pill ー a placebo. (The word comes from the Latin 4 化碼 "to please. " A physi- CIan sometlmes g1Ves a placebO tO anXIOLIS patlents tO placate them. ) SubJects will not be told which pill they receive. By uslng this improved experlmental procedure, we can infer that any observed differences in needle-threading ability of the two groups were produced by the pharmacological effects ofamphet- amine. The procedure is called a single-blind study; the subjects do not know what kind of pill they are taking. Do なれ d 立込 . Now let us 100k at an example in which it is lmportant tO keep bOth the experl- menter and the subjects in the dark. Suppose we believe that if patients with mental disorders take a particular drug, they will be easier to talk with. We give the drug tO some patients and administer a pla- cebo to others. 嶬み e talk with all of the patients after- ward and rate the quality Of the conversation. But quality 0f conversation" is a difficult dependent variable tO measure, and the rating is therefore likely tO be a somewhat subjective measurement ーは matter ofpersonalJtIdgment. ()n contrast, objective measurements are those that everyone agrees on and that do not rely 0 Ⅱ personaljudgment. ) The fact that we, the experlmenters, know which patients received the drug means that we may tend tO give higher ratmgs tO the quality Of conversatlon with those patlents. Of course, we , ould not lntentlon- ally cheat, but even honest people tend to percelve results in a way that favors their OW れ preconceptions. OBSERVATIONAL STUDIES There are S01 れ e variables, especially subject variables, that a psychologist cannot manipulate. For example, a person's sex, 1 Ⅱ C01 Ⅱ e , SOCial class, and personality are determined by factors not under the psycholo- Some variables, such as a person S sex, income, SOCial class, and personality cannot be controlled by the researcher, whO must perform an observational study tO investigate their effect on behavior.
CHAPTER 17 THE NATURE AND CAUSES OF MENTAL DISORDERS 590 nized that some patlents' symptoms were not lmproved by medication. Crow and his colleagues (Crow, 1980 ; Crow, Cross, Johnstone, and Owen, 1982 ) suggested that the reason for this failure to lmprove is that there are tWO types Of schizophrenic symptoms: positlve and negative. 2 の″ルどツ川川 5 include the hallmarks of schizophrenia: delusions, hallucinations, and thought disorders. N 鬯 4 ッ川た 川 include IOSS Of emotional response, decreased speech, lack of drive, and diminished social interac- tion. Because antlpsychotic drugs alleviate positlve, but not negative, symptoms Of schizophrenia (An- grist, R0trosen, and Gershon, 1980 ) , perhaps those patlents whO dO not get better with medication have pnmarily negative symptoms. Once lnvestigators began paymg 1 れ ore attentlon tO negative symptoms, they discovered evidence for brain damage in patients exhibiting these symptoms. For example, Stevens ( 1982a ) noted that many pa- tlents with chronic schizophrenia demonstrate symptoms that clearly indicate neurological disease, especially with regard t0 eye movements. ln addi- t10 Ⅱ , catatonla IS seen 1 Ⅱ nonpsychotic patlents with a variety Of neurological disorders. ・′・ he Ⅱ Stevens ( 1982b ) examined slices ofbrains ofdeceased schizo- phrenic patlents, she found clear evidence for brain damage that suggested either a disease process that had occurred earlier in life and had partly healed or one that was slowly progressmg at the time Of the patient's death. Other investlgators examined CT scans Of patients with schizophrenia. For example, Weinberger and 嶬/ ・ yatt ( 1982 ) found that the ven- tricles in the brains Of schizophrenic patlents were, 0 Ⅱ average, tWICe as large as those Of れ ormal subJectS. Similarly, pfefferbaum, Zipursky, Lim, Zatz, Stahl, and Jernigan ( 1988 ) found evidence that the sulci (the wrinkles in the brain) were wider in the brains Of schizophrenic patients. Enlargement 0f the hollow ventricles Ofthe brain and widening Ofthe sulci indi- cates the IOSS Of brain tlssue elsewhere; thus, the evi- dence implied the existence Of some kind Of neuro- logical disease. Loss Of brain tlssue, as assessed by CT scans, ap- pears tO be related tO negative symptoms Of schizo- phrenia but not tO POS1tive ones Oohnstone, Crow, Frith, Stevens, Kreel, and Husband, 1978 ). ln addi- tion, patients with IOSS Ofbrain tlssue respond poorly t0 antipsychotic drugs (Weinberger' Bigelow' Kleinman, Klein, Rosenblatt, and Wyatt' 1980 ). These studies suggest that positlve and negatlve symptoms Of schizophrenia have different causes: positive symptoms are a result Of overactivity Of dO- 600 (spuesnoql) 一 2 た dso 工 300 100 1900 1930 1975 1960 Year FIGURE 17.7 Number of patients in public mental hospitals from 1900 tO 1975. (Redrawn from Bassuk, E. L. , and Gerson, S. Deinstitutionalization and mental health services. Scientific American, 1978 , 238 , 46 ー 53. Copyright ◎ 1978 by Scientific American,lnc. AII rights reserved. ) tient with catatonic lmmobility tO begin 1 Ⅱ 0V1 れ g agam, as well as causmg an excited patient tO quiet down. ln contrast, true tranquilizers such as Librium or Valium 0 Ⅱ ly make a schizophrenic patlent SIOW moving and groggy ・ Amphetanune, cocalne, and the antipsychotic drugs act on synapses (the Junctions between nerve cells) in the brain. As you may recall 丘 om Chapter 3 , one neuron passes 0 Ⅱ excltatory or inhibitory sages tO another by releasing a small amount oftrans- mitter substance 伝 om lts terminal button intO the synaptic cleft. The chemical activates receptors on the surface Ofthe recelvlng neuron, and the activated receptors either exclte or inhibit the receivmg neuron. Drugs such as amphetamme and cocame cause the ゞ行川材行 0 れ Of receptors for dopamlne, a transmltter substance. ln contrast, antipsychotic drugs block dopamine receptors and ア化怩厩 them 丘 om becoming stimulated. These findings have led mvestigators tO hypothesize that schizophrenia may be caused by excesslve activity Of dopamme in the brain. Neurological Disorders Although the dopa- mine hypothesis has for several years been the domi- nant biological explanation for schizophrenia, recent evidence suggests that it can Offer 0 Ⅱ ly a partial ex- planation. From the early days 0f treating schizo- phrenia with antipsychotic drugs, clinicians recog-
increase transiently during the confrontation phase Of psychotherapy, and would drop following resolution 0f the issue. ln order t0 test this hypothesis, a psychoendocrine study during the psy- chotherapy Of six depressed female patients was carried out. Me 0 P れ t PO 〃材 tio れ Six female patients were selected from a larger group Of depressed patients admitted tO a research ward. Criteria for selection were: depressive illness Of recent onset; illness severe enough tO require hospitalization; a clear, apparent psychological precipitant; absence Of schizophrenic symptomatology in the pres- ent illness and in the premorbid character; no electroshock treatments or hor- mone therapy within one year Of admission; no active medical illness; and ap- parent suitability for short-term psychotherapy without somatic treatment. TO elaborate on the last criterion, patients were selected who appeared 朝 ) to be verbal and intelligent enough for psychotherapy, ( わ ) to be able to tolerate psychotherapeutic treatment without any somatic therapy (including sleeping medications), and (c) tO have a premorbid character judged not SO infantile as t0 preclude the ability tO dO the psychotherapeutic work. T 〃 2 Research Ward The research ward was a ten-bed unit at the Massachusetts Mental Health Center designed for study and treatment 0f affective disorders. A high staff-to- patient ratiO permitted intensive observation and management Of patients. Urine and blood collections were part of standard ward operating procedure. urine Co 〃 ec 巨 0 れ s TOtal urine output was collected in 24-hour units at least five days a week. Collections ran from 8 a. m. tO 8 a. m. Throughout hospitalization, completeness of urine collection was insured by enlisting the patients' cooperation, careful supervision Of the latrines, and analyzing each day's urine output for creatinine content. Following collection, the samples were stored in a frozen state until chemical analysis. Endocrine De 地 r 川ⅲ池れ s Urinary 17-hydroxycorticosteroids were analyzed by the Glenn-Nelson method12 ・ 13 for which, in our laboratory, the standard coefficient Of variation has been less than 5 %. Endocrine analyses were discounted on all days in which there was evidence Of incompleteness Of collection, interfering medications, intervemng somatic illness, or abnormal spectral curves on chemical assay. Treatment Program Each patient was assigned an administrative physician (the chief resident Of the research ward) and a psychotherapist (one of us or a colleague). AII drugs were excluded, with the exception Of aspirin, propoxyphene hydrochloride (Darvon), and vitamin preparations. Each patient saw his therapist twice weekly. Psychotherapy was psychoanalytic in orientation, the goals were short-term, and the emphasis was on confronting and resolving the precipitating depressive issue, that is, the loss and its meaning tO the patient. 362 Development 0 ー the lndividual
10 GE 0 WELL AGAIN 田 S 【賀 S OF Ⅱ & APPROACH After three years of teaching patients to use 市 e minds and emotions の alter the course Of their malignancies, we de- cided t0 conduct a study 城 m 記 at distinguishing the 0 e s 0f emotional and treatments tO demonstrate scientifically that the emotional treatment was indeed having an effect. We began studying a group patients with malignancies deemed medically incurable. Expected survival time for the average patient with such a malignancy is twelve months. ln the past f0 years, we have treated 159 patients with a diagonsis 0f medically incurable malignancy. S ⅸ - t 0f the patients are alive, with an average survival 0f 24.4 months since the diagnosis. Life expectancy for this group, b 記 on national norms, is 12 months. A matched control population is being developed and preliminary r ⅵ indicate survival comparable ⅵ山 national norms and 13S than a the survival time 0f 例江 patients. With the patients ⅲ our study who have died, 止 e む average survival time was 20.3 months. ln other words, the patients 遍 0 study wh0 are alive have lived, on the average, two times longer than pa- tients who received medical treatment alone. Even those pa- tients the study wh0 have died still lived one and one-half times longer than 止 0 部 oup ・ As 0f January 1978 , the status 0f the disease ⅲ the pa- ⅱ en still living follows: No evidence of disease Tumor regessing Disease stable New tumor growth Number Of patients 14 12 17 20 Percent 22.2 % 19.1 % 27.1 % 31.8 % Keep ⅲ mind that 18 percent Of 止 e patients were consid- ered medically incurable. Of course, duration of 1 達 e after diagnosis is only one - pect 0f the disease. Of equal ()r perhaps greater) importance is the quality of life while the patient survives. There are few existing objective masures Of quality Of life; however' 0 Ⅱ 0 measure we keep is the level 0f daily activity maintained dur- ing and after treatment compared の the level 0f ac ⅵ以 prior
T み Fa 〃ッ Su 〃 0 な S 221 Dishonesty will also be reflected in the physical health of the family members. The stress of dealing with a long-term and life-threatening disease can threaten yo own health, un- less you confront the problem openly. Certainly, there is pain ⅲ honesty, but in our experience it is mlnor compared with the pain of inevitable distance and isolation that occurs when people cannot b e themselves. The family may also find it diffcult to provide 酣 the emotional support the patient needs, due tO the intensity Of the relationship at this point and the fact that the family members have their own needs. However, there is no rule that limits warm and supportive relationships tO just the immediate fam- ily, and many patients benefit by establishing friendships and forming attachments with peop 厄 outside the family wh0 can give them some 0f the recognition and support they need. The patient's e 仕 0 t0 reach outside 0f the family should not be viewed as a sign that the family has failed. lt is unreasonable tO expect that family members can meet all the patient's emo- tional needs and still pay attention tO their own. BO 山 patient and family members can benefit from pen- Odic counseling tO resolve diffculties or gam support ⅲ learn- ing hOW tO meet their needs in a situation that is potentially guilt-inducing for everyone. A number 0f 0n810 depart- ments Offer family counseling services as part Of the treatment program. AISO, an increasing number 0f psychologist$ psy- chotherapists, and counselors are being trained in counseling cancer patients and their families, and most communities have qualified ministers and therapists. Family counseling is often helpful for opemng up com- munication and for providing a fe climate in which tO face anxiety-producing issues. lt can also help patients deal with some 0f 止 0 factors that may have contributed t0 their suscep- tibility to cancer in the first place. The almost inevitable financial burden prolonged illness places upon a family is another diffcult area that requlres openness and honesty. Typically, the financial burden can make family members feel guilty about spending money t0 meet their own nee . Our social conditioning suggests that whatever available money is not already committed tO necessi- ties should be set aside for the patient's needs. Yet patients also feel guilty about spending money, since it is their illness that has placed the financial drain on 山 e families ⅲ the first place.
625 BIOLOG ℃ AL TREATMENTS forty-four-year-old widow had been hospitalized for three months for severe depression. A course Ofthree ECT treatments per week was prescribed for her by her theraplst's supervisor. Unknown to her theraplst (a trainee), the first twelve treatments were sub- threshold; that is, the intensity of the electrical cur- rent was t00 10W tO produce selzures. (The treat- ments could be regarded as placebo treatments. ) Although both patient and therapist expected the " 01 れ an tO ShOW S01 e lmprovement, none was seen. ln the next fourteen treatments the current was raised tO a sufficient level tO produce selzures. After five actual seizures, bOth patient and therapist no- ticed an improvement. The , 01 Ⅱ a Ⅱ began tO com— plain less about various physical symptoms, tO partIC- lpate in hospital activltles, and tO make more positlve statements about her 1 Ⅱ 00d. she became easler tO talk with, and the therapist's notes Of their conversatlons lmmediately proliferated. The fact that these re- sponses occurred 0 Ⅱ ly after several actual seizures suggests that improvement stemmed れ the biO- logical treatment and not simply om the therapist's or the patlent's expectatlons. Some patients with n100d disorders dO れ Ot re- spond tO antidepressant drugs, but a substantial per- centage Ofthese patlents lmprove after a few seSSIOns ofECT. Because antidepressant medications are gen- erally slow acting, taking ten days to two weeks for their therapeutic effects tO begin, severe cases Of de- pression are Often treated with a briefcourse OfECT tO reduce the symptoms right away. The patients are then malntained on the antidepressant drug. Electro- convulsive therapy is also useful in treatlng pregnant women , hO have severe depresslon•, because the procedure does not involve long-term administra— tIOn Of drugs, the danger tO the fetus is mlnimized (Goodwin and Guze, 1984 ). Because a depressed person runs a 15 percent chance 0f dying by suicide, the use of electroconvulsive therapy may bejustified ln such cases. The second critlclsm of ECT, concerning the dangers inherent ln repeated treatment, is quite true. An excesslve number Of ECT treatments will pro- duce permanent loss of memory (Squire, Slater, and MiIIer, 1981 ) and probably also cognitive deficits. Nowadays, ECT is usually administered only to the right hemisphere, ln order tO 1 1 Ⅱ 11 れ ize damage tO people's verbal memories. Nevertheless, it is likely that even a small number oftreatments causes at least some permanent brain damage. Therefore, the PO- tential benefits of ECT must be weighed against its potential damage. Electroconvulsive therapy must FIGURE 18.10 A patient being prepared for electrocon- vulsive therapy. srons ー muscular rigidity and trembling, followed by rhythmic movements of the head, trunk, and limbs. After a few mmutes the person falls into a stuporous sleep. TOday patients are anesthetized and temporarily paralyzed before the current is turned on. This procedure eliminates the convulsion but not the seizure, which is what delivers the therapeutic effect. Electroconvulsive therapy has a bad reputation among many clinicians because it has been used tO treat disorders such as schizophrenia, on which it has no useful effects, and because patients have received excesslve numbers Of ECT treatments ーー as many as hundreds. Originally, ECT was thought to alleviate the symptoms Of schizophrenia, because schiZO- phrenic people who also had epilepsy often appeared tO improve 」 ust after a selzure. subsequent research has shown that ECT has little or Ⅱ 0 effect 0 Ⅱ the symptoms Of schizophrenia. However, it has been shown tO be singularly effective in treating severe depression (Baldessarini, 1977 ). Although no one knows for certain why ECT alleviates depresslon, possibly, it does so by reducing REM sleep. As we saw in Chapter 17 , people with maJ0r depressron engage in abnormally large amounts 0f REM sleep' and REM sleep deprivation is an effective antide- pressant therapy. A case report by Fink ( 1976 ) illustrates the re- sponse 0f a depressed patient t0 a course 0f ECT. A
2 The Mysteries HeaIing: The lndividual His Beliefs The awesome technology of modern medicine casts an image 0f such 部 t potency and knowledge that it is hard to believe 0 individual resources Ⅱ make much difference. Of course, Ⅱ 0 one would responsibly dismiss the advances of this age. lts accomplishments are among the 部 t t products 0f the human mind. ln cancer treatment 0 Ⅱら部 t advances have been made in radiation therapy, ⅲ sophisticated procedures for chemotherapy, and ⅲ s 1 techniques. As a result of this technology, from 30 to 40 per- cent Of all Ⅱ cer patients will be "cured ” of their disease. cancer patients receive their treatment from ma- chines 血 ous ⅲ special rooms posted with signs warning of the dangers Of radiation. The patients are le れ alone to wonder why, 山 0 treatment is supposed to do much good, 心 the medical s ね迂 members avoid it so. Other machines emit such 10 Ⅱ d noises and whines that the patient must wear rmu s. 0 latest diagnostic equipment is vast that the patient is wheeled into the machine, where sca may be taken of cross the body. Surgical teams use incredible sophisti- cated and expensive equipment ⅲ hours-long operations ⅲ・ 13
乙 ea g ね Relax 〃イ / な 44 e eco 阨 119 b0dy to alter the internal state but instead had leamed a visual and symbolic language by which they communicated with the body. One woman, wh0 had a dangerously irregular 五 b t , created a picture ⅲ her mind's eye 0f a little rl on a swmg. She would see the little girl rhythmically swinging back and forth whenever she needed to bring her heartbeat under 00n - trol. Within a short time, she needed no h medication and had no more diffculties. Her success and the experiences 0f thousands of others in using mental imagery t0 00ntr01 b0dy states suggested tO us that mental imagery—used ⅲ conjunc- tion with standard medical treatment—might be a way cancer patients could influence their immune systems tO become more active ⅲ fighting their illness. Carl first used the mental imagery technique ⅲ 1971 ( we described in Chapter 1 ) with a patient whose cancer was considered medically incurable. The patient practiced three times a day visualizing his cancer, his treatment commg in and destroying it, his white b100d cells attacking the cancer cells and flushing them out 0f his body, and finally imagming himself regaining health. The results were spectacular: The "hopeless ” patient overcame his disease and is still alive and healthy. TI-Æ MENTAL IMAGERY OC ln this section, we will lead you through the relaxation- mental imagery process, repeating the previous instructions for relaxation. ln Chapter 12 , we will identify beliefs inherent in mental imagery, provide a list 0f criteria for creating effec- tive imagery, and analyze examples drawn from our patients' expenences. You may want tO tape-record instructions, we dO fO て our patients, or have a friend read them tO you. Ⅱ you are reading tO someone else, be sure tO read slowly. AIIOW the 0ther person plenty 0f time t0 complete each step. Remember that we encourage our patients tO take ten tO fifteen minutes tO complete the entire process and tO practice it three times a day. Even you do not have cancer, we ask you tO go through the cancer visualization once tO give you an tional understanding Of this process and insight intO 五 OW the cancer patient feels.
WHY WE SLEEP 3 3 5 The third idea for sleep change within industry concerns medicine. AS urgent as the need tO inject more sleep in residents' work schedules is the need t0 radically rethink how sleep factors int0 patient care. I can illuminate this idea with い VO concrete examples. EXAMPLE I—PAIN The less sleep you have had, or the more fragmented your sleep, the more sensitive you are tO pain Of all kinds. The most common place where people expenence significant and sustained pain is Often the very last place they can find sound sleep: a hospital. If you have been unfortunate enough t0 spend even a single night ⅲ the hospital, you ⅶⅡ ow this t00 well. The problems are especially compounded in the intensive care unit, Where the most severely SiCk (). e. , those most in need 0f sleep's help) are cared 応 r. lncessant beeping and buzzing 仕 om eqmpment, sporadic alarms, and frequent te sts prevent anything resembling restful or plentiful sleep for the patient. Occupational health studies 0f inpatient rooms and wards report a decibel level 0f sound pollution that is equivalent t0 that of a noisy restaurant or bar, twenty-four hours as day.. As it turns out, 50 to 80 per- cent Of all intensive care alarms are unnecessary or ignorable by staff.. Additionally frustrating is that not all tests and patient cheékups are time sensitive, yet many are ill-timed with regard tO sleep. They occur either during afternoon times when patients would otherwise be enjoy- ing a natural, biphasic-sleep nap, or during early-mornmg hours when patients are only now settling int0 solid sleep. Little surprise that across cardiac, medical, and surgical intensive care units, studies consistently demonstrate uniformly bad sleep ⅲ all patients. Upset by the noisy, unfamiliar ICU environment, sleep takes longer t0 initiate, is littered with awakenings, is shallower in depth, and contains less overall REM sleep. Worse still, doctors and nurses con- sistently overestimate the amount Of sleep they think patients Obtain in intensive care units, relative tO objectively measured sleep in these individuals. AII told, the sleep environment, and thus sleep amount, 0f a patient in this hospital environment is entirely antithetical tO their convalescence. We can solve this. lt should be possible to design a system of medi-
T み Fa 〃ァ & po け 217 lt is also damaging to try to protect the patient 仕 om 0ther family problems, such 颶 a child's diffculties 血 s 001. Taking the attitude that the patient "already has so many problems ” isolates him or her from the family precisely at the time when it is most important for the patient feel commit- ted t0 and involved with life. CIoseness comes 丘 om sharing feelings: the moment feelings are withheld, closeness begins t0 be lost. The patient can also assume the rescuer role, most 仕ト quently by "protecting ” family members by not expressing 届 & or her fears and anxieties. ln the process, the patient becomes increasingly isolated from the family. Rather than protecting, the patient is actually excluding the family and ing a lack 0f trust ⅲ his or her loved ones. When are "rescued ” from their feelings, they dont have an opportunity t0 experience and resolve them. As a result, family members may continue t0 have unresolved feelings long after the patient has recovered or 記 . Just as the family needs t0 avoid trying t0 rescue the pa- tient 仕 om the joys and pains 0f everyday family life, patients need t0 avoid trying t0 rescue their families from painful f31- ings. ln the long run, everybody's p Ch010 1 health is - proved when feelings are openly dealt with and resolved. Helping, 第 er 節 a 取 e g lt is easy t0 see how the escue Game could get started between a cancer patient and a spouse. AII our cultural condi- tioning says that the way 10V 血 g people should respond t0 Ⅲ - ness is by taking over for the patients dOing everything for them, helping them t0 the point that they need d0 nothing ・ This v patients no responsibility for 止 e 辷 own well-being. The key is t0 be helpful instead Of smothering. However' there is sometimes a fine line between the tWO. 0 cri 51 element ⅲ helping is that it is something you な t0 d0 because it you f31 g00 not because 0f something you expect from the person yo helped. Anytime you find yourself getting resentful or angry, you can be sure you did something 山 an e ゆ ec ね on 0f ow the 0ther person should respond. And the habit may be deeply ⅲ凾 n . order t0 break it' you need tO pay close attention tO your feelings ・ steiner suggests three 0ther clues that will help you iden- tify rescuing behavior. You are rescuing if: