Psychopathology

Statistical infrequency

Defining abnormality in terms of statistics. For example, the number of times something observed.

Behaviour that is rarely seen is ‘abnormal’ i.e. a statistical infrequency.

E.g IQ and intellectual disability disorder IQ is normally distributed, the average is 100 (most people being between 85 and 115). Those scoring below 70 are statistically ‘abnormal’.

Deviation from social norms

Abnormality is based on social context. When someone behaves different from how they’re expected they’re defined as abnormal. Societies and social groups make collective judgements about ‘correct’ behaviours in particular circumstances.

There are few behaviours considered universally abnormal as the definitions are related to cultural context which includes historical differences within the same society. For example, homosexuality is considered abnormal in some societies and used to be in our society.

E.g antisocial personality disorder has an important symptom which is failure to conform to ‘lawful and culturally normative ethical behaviour’.

A psychopath is abnormal as they deviate from social norms - generally lacking empathy.

Failure to function adequately

Inability to cope with everyday living. E.g not being able to maintain basic standards of hygiene or hold down a job.

Rosenham and Seligman (1989) proposed signs of failure to cope:

• no longer conform to interpersonal rules (personal space)

• experience severe personal distress

• behave in a way that’s irrational/dangerous

E.g intellectual disability disorder - Having a low IQ is statistical infrequency but diagnosis wouldn’t be given on that alone. There would have to be signs the person couldn’t cope with the demands of everyday living.

Deviation from ideal mental health

To look at what makes someone ‘normal’ and psychologically healthy. Then identify anyone who deviates from this.

Jahoda (1958) listed 8 criteria.

E.g Someone’s inability to keep a job may be a sign of their failure to cope with the pressure of work.

Jahoda (1958)

Suggested the following criteria for ideal mental health:

1. We have no symptoms of distress.

2. We are rational and perceive ourselves accurately.

3. We self-actualise.

4. We can cope with stress.

5. We have a realistic view of the world.

6. We have good self-esteem and lack guilt.

7. We are independent of other people.

8. We can successfully work, love and enjoy our leisure.

AO3 of statistical infrequency (application)

Strength of statistical infrequency - It’s useful in diagnosis, e.g intellectual disability disorder requires IQ in the bottom 2%. It’s also helpful in assessing a range of conditions, e.g the BDI assesses depression where only 5% of people score 30+ (which means severe depression).

This shows statistical infrequency is useful in diagnostic and assessment processes.

AO3 of statistical infrequency (positives)

Limitation of statistical infrequency - If very few people display a behaviour, it’s statistically infrequent but it doesn’t always mean we’d call them abnormal.

E.g IQ scores above 130 are just unusual as those below 70 but not regarded as undesirable or needing help.

This shows whilst statistical infrequency can be part of defining abnormality it can’t be its sole basis.

AO3 of deviation from social norms (application)

Strength of deviation from social norms - It’s useful in the diagnosis of antisocial personality disorder. It requires failure to conform to ethical standards.

It’s also helpful diagnosing schizotypal personality disorder which involved ‘strange’ beliefs and behaviour.

This means deviation from social norms is useful in psychiatric diagnosis/has real-world application.

AO3 of deviation from social norms (cultures)

A person from one culture may label someone from another culture as abnormal using their standards rather than that person’s standards. For example, hearing voices is socially acceptable in some cultures but would be a sign of abnormality in the UK.

This means it’s difficult to judge deviation from one context to another.

AO3 of failure to function (help)

Strength of failure to function is that it’s a threshold for professional help - In a year 25% of us experience symptoms of mental disorder. Most press on but when we cease to function adequately people seek help.

This means this criterion provides a way to target treatment and services to those who need them most.

AO3 of failure to function (discrimination)

Limitation of failure to function - It’s hard to distinguish between failure to function and a conscious decision to deviate from social norms. For example, people may choose to live off-grid as a life-style choice or take part in high risk activities.

People who make unusual choices can be labelled as abnormal and their freedom of choice restricted.

AO3 of deviation from ideal mental health (comprehensive)

Strength of deviation from ideal mental health - Includes a range of criteria for mental health which covers most of the reasons we might need help. This means mental health can be discussed with professionals.

Ideal mental health provides a checklist against which we can assess ourselves and others.

AO3 of deviation from ideal mental health (standards)

Limitation of deviation from ideal mental health - Few of us attain all Jahoda’s criteria for mental health and none maintain them. It’s an impossible set of standards which then means everyone deviates from ideal mental health.

Therefore, the list may not be an accurate list of criteria for mental health and need to be reevaluated.

Behavioural characteristics of phobias

• Panic - May involve crying, screaming or running away from the phobic stimulus

• Avoidance - Considerable effort to prevent contact with phobic stimulus which can make it hard to go about everyday life

• Endurance - Alternative behaviour to avoidance. Involves remaining with phobic stimulus and continuing experiencing anxiety.

Emotional characteristics of phobias

• Anxiety - Unpleasant state of high arousal which prevents individual relaxing making it very difficult to experience positive emotion

• Fear - Immediate response when we encounter/think about phobic stimulus

• Emotional response is unreasonable - Disproportionate to the threat posed, e.g a person with arachnophobia will have a strong emotional response to a tiny spider.

Cognitive characteristics of phobias

• Selective attention to the phobic stimulus - Person finds it hard to look away from phobic stimulus

• Irrational beliefs - May involve beliefs ‘If I blush people will think I’m weak’.

• Cognitive distortions - Unrealistic thinking e.g belly buttons appear ugly

Behavioural characteristics of depression

• Activity level - Have reduced levels of energy, e.g can’t get out of bed

• Disruption to sleep and eating behaviour - Reduced sleep (insomnia)/increased (hypersomnia). Appetite/weight may increase/decrease.

• Aggression and self-harm - Associated with irritability which may progress to aggression and self-harm

Emotional characteristics of depression

• Lowered mood - Describe themselves as ‘worthless’ or ‘empty’

• Anger - Emotions lead to aggression/self-harming behaviour

• Lowered self-esteem - They like themselves less, even self-loathing

Cognitive characteristics of depression

• Poor concentration - May find themselves unable to stick with a task or find decision making difficult

• Attention to the negative - Have bias towards negative aspects of current situations and recalling unhappy memories

• Absolutist thinking - When a situations is unfortunate its seen as a disaster, ‘black-and-white thinking’

Behavioural characteristics of OCD

• Compulsions are repetitive - Actions carried out in a ritualistic way, e.g hand washing

• Compulsions reduce anxiety - Anxiety may be from obsessions, or just anxiety alone

• Avoidance - Managed by avoiding situations that trigger anxiety, e.g avoid rubbish bins because they have germs

Emotional characteristics of OCD

• Anxiety and distress - Obsessive thoughts unpleasant, anxiety overwhelming

• Depression - Low mood and lack of enjoyment

• Guilt and disgust - Irrational guilt (e.g over minor moral issue) or disgust directed at oneself or something external

Cognitive characteristics of OCD

• Obsessive thoughts - 90% of people with OCD have recurring intrusive thoughts, e.g about being contaminated by dirt/germs

• Cognitive coping strategies - People use strategies to cope, e.g meditation

• Insight into excessive anxiety - Awareness that thoughts/behaviours are irrational. They may have catastrophic thoughts and be hypervigilant

Mowrer (1960)

Argued that phobias are learnt by classical conditioning and then maintained by operant conditioning, i.e. two processes are involved.

Classical conditioning to explain phobias

Classical conditioning involves association:

1. UCS triggers a fear response (fear is UCR), e.g being bitten creates anxiety

2. NS is associated with the UCS, e.g being bitten by a dog (the dog previously did not create anxiety)

3. NS becomes CS producing fear (which is now the CR). The dog becomes a CS causing a CR of anxiety/fear following the bite

Watson and Rayner (1920)

Showed how a fear of rats could be conditioned in 'Little Albert'.

1. Whenever Albert played with a white rat, a loud noise was made close to his ear. The noise (UCS) caused a fear response (UCR).

2. Rat (NS) did not create fear until the bang and the rat had been paired together several times.

3. Albert showed a fear response (CR) every time he came into contact with the rat (now a CS).

Generalisation (in conditioning terms)

Generalisation of fear to other stimuli. For example, Little Albert also showed a fear in response to other white furry objects including a fur coat and a Santa Claws beard

Maintenance by operant condition

Operant conditioning takes place when behaviour is reinforced or punished.

Negative reinforcement - an individual produces behaviour that avoids something unpleasant.

When a person avoids a phobic stimulus they escape anxiety.

This negatively reinforces the avoidance behaviour and the phobia is maintained.

Negative reinforcement example

If someone has a morbid fear of clowns (coulrophobia) they will avoid circuses and other situations where they may encounter clowns.

The relief felt from avoiding clowns negatively reinforces the phobia and ensures it is maintained rather than confronted.

AO3 of the two-process model (application)

Strength of the two-process model - Idea that phobias are maintained by avoidance is important in explaining why people with phobias benefit from exposure therapies.

Once avoidance is prevented it ceases to be reinforced by the reduction of anxiety and avoidance behaviour declines.

This shows the value of the two-process model as it identifies treatment for phobias so it has real-world application.

AO3 of the behavioural approach to explaining phobias (explanation)

Limitation of the behavioural approach to explaining phobias - The two-process model is geared towards explaining behaviour. But, we know phobias also have a cognitive component (people hold irrational beliefs about their phobias).

This means the two-process model doesn’t fully explain the symptoms of phobias. It has an inability to explain cognitive aspects.

AO3 of behavioural approach to explaining phobias (De Jongh et al. (2006))

Strength of behavioural approach explaining phobias - Found that 73% of dental phobics had experienced a trauma (mostly involving dentistry), evidence of link between bad experiences and phobias. Further support came from the control group of people with low dental anxiety, where only 21% had experienced a traumatic event.

This confirms that the association between stimulus (dentistry) and an unconditioned response (pain) does lead to the phobia.

Counterpoint to conditioning causing phobias that De Jongh et al. proved

Not all phobias appear following a bad experience. For example, snake phobias still occur in populations where very few people have any experience of snakes. Also not all frightening experiences lead to phobias.

This means that behavioural theories probably do no provide an explanation for all cases of phobia.

Systematic desensitisation (SD)

Therapy aims to gradually reduce anxiety through counterconditioning:

• Phobia is learned so that phobic stimulus produces fear

• CS is paired with relaxation which becomes the new CR

Client and therapist form anxiety hierarchy. Relaxation practised at each level of the hierarchy after being taught relaxation techniques.

It takes place over several sessions and is finished when a client can stay calm in high-anxiety situations.

Reciprocal inhibition

Not possible to be afraid and relaxed at the same time, so one emotion prevents the other.

Anxiety hierarchy

Client and therapist form this.

Fearful stimuli arranged in order from least to most frightening.

For example, a person with arachnophobia might identify seeing a picture of a small spider as low of their anxiety hierarchy and holding a tarantula as the final item.

Flooding

Immediate exposure to the phobic stimulus.

Involves exposing a person with the phobic object without a gradual build-up.

For example, person with arachnophobia may have a large sider crawl on them until they relax.

It’s an unpleasant experience so people having the treatment must give informed consent and know the expect or be fully prepared.

Extinction

In terms of flooding:

Without the option of avoidance behaviour, the person quickly learns that the phobic object is harmless through the exhaustion of their fear response.

AO3 of systematic desensitisation **(**Gilroy et al. (2003))

Strength of systematic desensitisation - Followed up 42 people who had SD for spider phobia. At follow-up, the SD group were less fearful than a control group.

This means that SD is likely to be helpful for people with phobias.

AO3 of systematic desensitisation (Wechsler et al. (2019))

Strength of systematic desensitisation - In a recent review they concluded that SD is effective for specific phobia, social phobia and agoraphobia. This means that SD is likely to be helpful for people with phobias.

AO3 of systematic desensitisation (learning disabilities)

Main alternatives to SD are unsuitable for people with learning disabilities, e.g cognitive therapies require a high level of rational thought and flooding is distressing.

SD, on the other hand, does not require understanding or engagement on a cognitive level and is not a traumatic experience.

This means that SD is often the most appropriate treatment for some people.

AO3 of flooding (cost)

Strength of flooding - It can be described as cost-effective as it’s clinically effective and not expensive. It can work in as little as one session. Even though the sessions are long it’s more cost-effective than alternatives.

This means more people can be treated at the same cost by flooding than SD or other therapies.

AO3 of flooding (Schumacher et al. (2015))

Limitation of flooding - Found that both participants and therapists rated flooding as more stressful than SD. Thus there are ethical concerns about knowingly causing stress (offset by informed consent), and the traumatic nature of flooding also leads to higher attrition rates than for SD.

This suggests that, overall, therapists may avoid using this treatment.

Negative self-schema

A schema is a ‘package’ of ideas and information developed through experience. We use schema to interpret the world, so if a person has a negative self-schema they interpret all information about themselves in a negative way.

Beck (1967)

Negative triad - Suggested that some people are more prone to depression because of faulty information processing, i.e. thinking in a flawed way.

When depressed people:

• attend to the negative aspects of a situation and ignore positive

• they tend to blow small problems out of proportion

• think in 'black-and-white' terms

There are three elements to the negative triad:

• Negative view of the world, e.g. 'the world is a cold hard place'.

• Negative view of the future, e.g. 'there isn't much chance that the economy will get any better'.

• Negative view of the self, e.g. thinking 'I am a failure' and this negatively impacts upon self-esteem.

Ellis (1962)

ABC model (Activating event, Beliefs, Consequences)

A - Ellis suggested that depression arises from irrational thoughts. According to Ellis depression occurs when we experience negative events.

For example, failing an important test or ending a relationship.

B - Negative events trigger irrational beliefs, for example:

• Ellis called the belief that we must always succeed musterbation.

• I-can't-stand-it-itis is the belief that it is a disaster when things do not go smoothly.

• Utopianism is the belief that the world must always be fair and just.

C - When an activating event triggers irrational beliefs there are emotional and behavioural consequences.

For example, if you believe you must always succeed and then you fail at something, the consequence is depression.

AO3 of Beck’s Model (Clark and Beck (1999))

Strength of Beck's Model - Concluded that cognitive vulnerabilities (e.g. faulty information processing, negative self-schema) are more common in depressed people.

This shows that there is an association between cognitive vulnerability and depression.

AO3 of Beck’s Model (Cohen et al. (2019))

Strength of Beck's Model - Prospective study that tracked 473 adolescents' development and found that early cognitive vulnerability predicted later depression.

This shows that there is an association between cognitive vulnerability and depression.

AO3 of Beck’s model (application)

Strength of Beck’s model - It can assess cognitive vulnerability in young people most at risk of developing depression meaning they can be monitored. Understanding cognitive vulnerability is applied in CBT to alter cognitions underlying depression.

The idea of cognitive vulnerability is useful in clinical practice.

AO3 of Beck’s model (partial)

Depressed people show patterns of cognition even before onset depression. So, Beck’s model is at least a partial explanation.

Some aspects of depression are not explained through cognitive factors, such as anger, hallucinations and delusions.

This suggests the cognitive model is not a great explanation for all depression.

AO3 of Ellis’s Model (David et al. (2018))

Strength of Ellis’s model - Ellis applied the ABC model to treat depression (rational emotive behaviour therapy, REBT). Evidence that REBT can both change negative beliefs and relieve the symptoms of depression.

This means that REBT has real-world value.

AO3 of Ellis’s ABC model (explain)

Reactive depression is a form where it’s triggered by negative activating events.

In many cases it isn’t obvious whats triggering depression (endogenous depression), and Ellis’s model is less useful in explaining this.

This means Ellis’s model can only explain some cases of depression.

Cognitive behavioural therapy (CBT)

CBT is an example of the cognitive approach to treatment, also includes behavioural aspects:

• cognitive - challenge negative, irrational thoughts

• behaviour - change behaviour so it’s more effective

Client and therapist work together.

Most common psychological treatment.

Challenge negative thoughts

The aim in CBT is to identify negative thoughts about the self, the world and the future (the negative triad)

These thoughts must be challenged by the client taking an active role in their treatment.

‘client as scientist’

Clients encouraged to test the reality of their irrational belief.

Might be set homework (e.g to record when they enjoyed an event").

In future if the client says no ones nice to them the therapist can produce evidence to prove their beliefs are incorrect.

Ellis’s rational emotive behaviour therapy (REBT)

REBT extends the ABC model to an ABCDE model where:

• D is for dispute (challenge) irrational beliefs

• E is for effect

Challenging irrational thoughts

Client might say how unfair life is. An REBT therapist would identify this as utopianism and challenge it as irrational.

• Empirical argument - disputing whether there is evidence to support the irrational belief

• Logical argument - disputing whether the negative thoughts actually follows from the facts

Behavioural activation

As individuals become depressed, they tend to increasingly avoid difficult situations and become isolated which maintains symptoms.

The goal of behavioural action is to work with them to gradually decrease their avoidance, isolation and increase engagement in activities they enjoy.

AO3 of CBT (March et al. (2007))

Strength of CBT - Compared the effects of CBT with antidepressant drugs and a combination of the two in 327 depressed adolescents.

After 36 weeks 81% of CBT groups, 81% of antidepressants group and 86% of CBT + antidepressants group were significantly improved.

This means that there is a good case for making CBT the first choice of treatment in public health care systems like the NHS.

AO3 of CBT (Sturmey (2005))

Limitation of CBT - Suggests any form of psychotherapy (including CBT) is not suitable for people with learning difficulties.

This mean that CBT may only be appropriate for a specific range of clients.

Counterpoint to Sturmey (2005) (CBT not being applicable to people with learning difficulties)

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Taylor et al. (2008)- Concluded that CBT can be effective for people learning disabilities.

Lewis and Lewis (2016) - Concluded that CBT was as effective as other treatments for severe depression.

This means that CBT may have much wider application than was once thought.

AO3 of CBT (Ali et al. (2017))

Limitation of CBT - Assessed depression for 12 months following a course of CBT.

42% relapsed within six months of ending treatments and 53% within a year.

This means that CBT may need to be repeated periodically.

AO3 of CBT (Yrondi et al. (2015))

Limitation of CBT - Some clients prefer to take medication of explore the past, some rate CBT as least preferred therapy.

This suggests that people, even those who are depressed, should have the right to choose their therapy even if it may not be the one with the best evidence of effectiveness.

Candidate genes

Researchers have identified specific genes which create a vulnerability for OCD, called candidate genes.

• Serotonin genes, e.g 5HT1-D beta, are implicated in the transmission of serotonin across synapses.

• Dopamine genes are also implicated in OCD and may regulate mood.

Both dopamine and serotonin are neurotransmitters.

Taylor (2013)

Found evidence that up to 230 different genes may be involved in OCD.

Different types of OCD

One group of genes may cause OCD in one person but a different group of genes may cause the disorder in another person.

Theres also evidence that different types of OCD may be the result of particular genetic variations, such as hoarding disorder and religious obsession.

Neural explanations (low-levels of serotonin)

Low levels of serotonin lowers mood.

Neurotransmitters relay one neuron to another so low levels of serotonin means normal transmission cannot take place and mood is affected.

Neural explanation (frontal lobes)

Some cases of OCD can be associated with impaired decision-making.

This study may be associated with abnormal functioning of the lateral frontal lobes of the brain, as they are responsible for logical thinking and making decisions.

Parahippocampalgyrus dysfunctional

There is also evidence to suggest that an are called the left parahippocampal gyrus, associated with processing unpleasant emotions, functions abnormality in OCD.

AO3 of genetic explanations of OCD (Nestadt et al. (2010))

Strength of genetic explanations of OCD - Reviewed twin studies and found that 68% of identical twins (MZ) shared OCD as opposed to 31% of non-identical (DZ) twins.

This means that people who are genetically similar are more likely to share OCD, supporting a role of genetic vulnerability.

AO3 genetic explanations of OCD (Marini and Stebnicki (2012))

Strength of genetic explanations of OCD - Found that a person with a family member with OCD is around four times as likely to develop it as someone without.

This means that people who are genetically similar are more likely to share OCD, supporting a role of genetic vulnerability.

AO3 of genetic explanations of OCD (Cromer et al. (2007))

Limitation of genetic explanation of OCD - Found in one sample over half of people with OCD experienced a traumatic event.

OCD severity correlated positively with number of traumas.

This means that genetic vulnerability only provides a partial explanation for OCD>

AO3 of neural explanations (evidence)

Strength of neural explanations - Antidepressants work on serotonin to reduced OCD symptoms. This suggest serotonin may be involved in OCD. OCD symptoms form part of conditions that are known to be biological in origin.

This means biological factors are likely to be involved in OCD.

AO3 of neural model (cross-over)

Many people with OCD also experience depression. This probably involves disruption to the action of serotonin.

It could simply be serotonin activity is disrupted in many people with OCD because they are depressed as well.

This means serotonin may not be relevant to OCD symptoms.

Changing levels of neurotransmitters

Drug therapy for mental disorders dims to increase or decrease levels of neurotransmitters in the brain or to increase/decrease this activity. Low levels of serotonin are associated with OCD.

Therefore drugs work in various ways to increase the level of serotonin in the brain.

SSRIs

SSRIs (selective serotonin re-uptake inhibitors) prevent the reabsorption and breakdown of serotonin in the brain. This increases it’s level in the synapse and thus serotonin continues to stimulate the postsynaptic neuron.

This compensates for whatever is wrong with the serotonin system in OCD.

Typical dosage

A typical daily dose of fluoxetine (an SSRI) is 20mg although this may be increased if it isn’t benefitting the person.

It takes 3-4 months of daily use for SSRIs to impact upon symptoms.

Dose can be increased (e.g. 60mg a day) if this is appropriate.

Combining SSRIs with CBT

Drugs are often used alongside CBT.

They reduce a person’s emotional symptoms, feeling anxious/depressed.

This means they engage more effectively with CBT.

Alternative to SSRIs

Tricyclics - These have the same effect on the serotonin system as SSRIs but the side-effects can be more severe.

SNRIs - Second line of defence for people who don’t respond to SSRIs. SNRIs increase levels of serotonin as well as noradrenaline.

AO3 of drug therapy for treating OCD (Soomro et al. (2009))

Strength of drug therapy for treating OCD - Reviewed 17 studies of SSRIs for the treatment of OCD. All 17 studies showed better outcomes following SSRIs than placebos. Typically OCD symptoms reduce for around 70% if people taking SSRIs.

This means that drugs can be of help to most people with OCD.

Counterpoint to drugs helping OCD (Skapinkais et al. (2016))

Counterpoint to Soomro et al. (2009) - Although drug treatments may be better than placebos, they may not be the most effective treatments. Cognitive and behavioural (exposure) therapies may be more effective than SSRIs in the treatment of OCD.

This means that drugs may not be optimum treatment for OCD.

AO3 of drug therapy (preference)

Drug treatments are cost-effective and non-disruptive. They are cheap compared to psychological treatment. Using drugs to treat OCD is good value for the NHS. As compared to psychological therapies, SSRIs are also non-disruptive to people’s lives.

This means many doctors and people with OCD prefer drug treatments.

AO3 of drug therapy (quality of life)

Limitation of drug therapy - A minority of people taking SSRIs get non benefit. Some people also experience side effects such as indigestion, blurred vision and loss of sex drive.

With clomipramine 1 in 10 people experience erection problems and weight gain, 1 in 100 become aggressive.

This means quality of life can poor meaning they stop taking them which reduces their effectiveness.

AO3 of drug therapy (Goldacre (2013))

Limitation of drug therapy - Some psychologists believe that the evidence for effectiveness is biased because of drug company sponsorship.

On the other hand, the best evidence available is supportive of the usefulness of drugs for OCD, and evidence for psychological therapies is biased too.

This means that as far as we know drugs are helpful for treating OCD, so it may be preferable to continue using them.