CLINICAL PSYCHOLOGY

what constitutes a phobia

specific phobias for objects or situations, agoraphobia and social anxiety

typically caused by a NS and UCS paired together conditioning fear toward the NS

describe the behavioural effects of a phobia

panic, avoidance or endurance of the stimulus

describe the emotional effects of a phobia

unreasonable anxiety and fear

describe the cognitive effects of a phobia

selective attention towards the phobic stimulus, irrational beliefs about it and cognitive distortions of it

define behavioural approach

behavioural characteristics of phobias are of primary importance

describe the two-process model

mowrer’s idea that phobias are a. learned and b. maintained

define classical conditioning

acquisition of phobias - neutral stimulus associated with fear, then becomes phobic object

define operant conditioning

maintains phobia - negative reinforcement because avoidance reduces anxiety

supporting evidence for classical conditioning: little albert

classical conditioning as an explanation for the acquisition of phobias is supported by watson and rayner’s research into little albert. they found that little albert initially showed no fear of a white rat, but after the rat was repeatedly paired with a loud, frightening noise, he began to show a fear response to the rat alone, which also generalised to similar stimuli such as a rabbit and a fur coat. this suggests that phobias are acquired through association with an unpleasant experience, meaning the two-process model is likely to be valid. further evidence comes from davey’s study on fear of dental treatment, which found that many individuals with dental phobias reported having a previous traumatic or painful experience at the dentist. this further increases the validity of the two-process model as it demonstrates that phobias can be learned through classical conditioning in real-life settings

limitations of behavioural approach

• very simplistic - ignores cognitive factors that could play a role in the development of phobias. our thought process and how we think about the feared stimulus is also important and how we focus our attention

• it can’t explain all phobias. for example, the two-process model suggests that phobias develop through a fast, automatic emotional pathway and a slower, rational pathway, yet some phobias appear without any direct traumatic experience or identifiable learning process. this suggests that not all phobias can be accounted for by these two thinking systems alone. as a result, the two-process model may be limited in its explanatory power, as it overlooks other factors such as genetic predisposition or evolutionary influences, reducing its ability to fully explain the development of phobias

• seligman’s concept: we tend to acquire phobias of things that have presented danger in our evolutionary past such as animals and the dark- we developed a phobia because is it an adaptive advantage to fear such objects

treatments for phobias

• systematic desensitisation

• flooding

prevent avoidance behaviour so the phobia cannot be maintained

describe the behavioural approach to treating phobias 

a way of explaining behaviour in terms of what is observable and in terms of learning. if we assume a phobia has been learned then is should be possible to unlearn it

describe systematic desensitisation

a behavioural therapy based on learning. designed to reduce an unwanted response, such as anxiety. SD involves drawing up a hierarchy of anxiety-provoking situations related to a person’s phobic stimulus, teaching the person to relax, and then exposing then to the phobic situations. the person works their way through the hierarchy whilst maintaining relaxation

what is an anxiety hierarchy

list of situations involving the phobic stimulus, ranging from situations that produce low levels of anxiety up to the most anxiety-producing situation

how is relaxation achieved in SD

client taught relaxation techniques or introduced to anti-anxiety medication

reciprocal inhibition - relaxation and anxiety can’t happen at the same time

what is SD an example of?

counterconditioning - being taught a new association, thus removing the original association. the phobic stimulus is paired with a relaxing stimulus until it triggers relaxation not anxiety

describe flooding

a behavioural therapy in which a person with a phobia is exposed to an extreme form of a phobic stimulus in order to reduce anxiety triggered by that stimulus. this takes place across a small number of long therapy sessions

what is extinction

in conditioning theory, the disappearance of a learned response when stimuli stop being paired (classical conditioning) or no reinforcement occurs (operant conditioning)

key features of clinical trials

• random allocation to conditions

• use of a control group; no treatment, placebo or alternative treatment​

• blind procedures (single or double)

supporting research for SD - gilroy et al. 2003

followed up 42 people who had systematic desensitisation for spider phobia in three 45-minute sessions. at both three and 33 months, the systematic desensitisation group were less fearful than a control group treated by relaxation without exposure

supporting research for SD - wechsler et al. 2019 meta-review

conducted a meta-review on the effectiveness of systematic desensitisation in the treatment of specific phobias, social phobia and agoraphobia and found that it was consistently more effective in reducing the fear response compared to other treatments. however, the research also showed that using VR headsets was less effective in treating social phobias, possibly due to the complex nature of social phobias and the lack of realism with VR

supporting research for behavioural therapies - smith and glass 1977 meta-analysis

conducted a meta-analysis on the effectiveness of systematic desensitisation and flooding in the treatment of phobias and found an average effect size of 0.91 (based on 223 studies) for systematic desensitisation and an average effect size of 0.64 (based on 45 studies) for flooding, showing that both treatments are more effective than control conditions (no treatment or alternative treatments)

non-supporting evidence for behavioural therapies

some critics argue that behavioural therapies only mask symptoms and do not tackle the underlying causes of phobias, meaning that whilst one phobia may be ‘cured’, another phobia develops shortly after. this is known as symptom substitution. for example, persons (1986) reported the case of a woman with a phobia of death who was treated using flooding. her fear of death declined but her fear of being criticised got worse

appropriateness of flooding

• no side effects

• more cost effective than SD as one long session

• free on HNS

• but cost of training clinicians which may impact waiting lists

• some risk of risks - may be traumatic due to long exposure and avoidance prevention

• this may increase attrition (drop out rates) so some may go untreated

• not appropriate for extreme phobias and young children

appropriateness of SD

• no side effects

• cost effective as set number of sessions and highly effective

• free on the NHS

• but cost of training clinicians which may impact waiting lists

• may cause some stress but gradual exposure and must get fully informed consent - low risk of risks

• better than cognitive therapies for those with learning difficulties - suitable for more patients

define depression

a mental disorder characterised by continuous low mood and low energy levels

behavioural characteristics of depression

• change in activity levels - lethargy; avoiding contact with friends / reduction in social activities; moving or speaking more slowly than usual; neglecting hobbies or interests; psychomotor agitation (unintentional and purposeless motions associated with high levels of distress) 

• disruption to sleep and eating behaviour - sleep: insomnia (difficulty falling or staying asleep); hypersomnia (sleeping too much), eating: poor appetite (leading to weight loss); overeating (comfort eating leading to weight gain) 

• aggression - towards others (linked to anger and irritability) or towards self (self-harm) 

emotional characteristics of depression

• lowered mood - must be continuous; sadness; feeling tearful; not getting enjoyment out of life; feeling anxious or worried

• lowered self-esteem - feeling hopeless and helpless; self-loathing

• anger - rare but can be extreme: irritable and intolerant of others; linked to self-harm when directed towards self  

cognitive characteristics of depression

• poor concentration - difficulties staying on task; finding it difficult to make decisions; having no motivation or interest in things 

• attending to and dwelling on the negative - rumination; ignoring positive aspects of a situation; focusing on negative memories from the past; having suicidal thoughts or thought of harming self 

• absolutist thinking - ‘black-and-white thinking’; focusing on extremes, e.g., if it is not perfect, it is a disaster

describe beck’s theory

explain vulnerability to depression in cognitive terms

beck's negative triad: some people think in ways that make them cognitively vulnerable to depression

negative thinking patterns = made individual more vulnerable to depression

negative thinking patterns = negative schemas = affect how we process info

negative schemas = often acquired through childhood

what is faulty information processing

selective attention to the negative aspects of situations

what is a negative self-schema

these affect how we interpret any new information relevant to us

what is the negative triad

negative view of the world, self and future

describe ellis’ ABC model

irrational beliefs make us overreact to events and get depressed

ellis's ABC model: irrational thoughts (any thoughts that interfere with us being happy and free from pain) affect our behaviour and emotional state

activating event triggers beliefs which are irrational, this produces consequences - an emotional or behavioural response e.g. depression

the irrational beliefs trigger the depression not the activating event

what is musturbatory thinking

irrational, rigid thought patterns thinking you ‘must’ do something for absolute perfection

what is i-can't-stand it-itis/catastrophising

if things don't happen as planned, it's a disaster

what is utopianism

thinking that life should always be fair

supportive evidence for beck’s negative triad

research conducted by clark and beck concluded that not only were negative thinking styles more common in people with depression, they have also been shown to precede depression. this was also shown in a prospective study by cohen et al. which tracked the development of 473 adolescents, regularly measuring cognitive vulnerability. It was found that showing cognitive vulnerability predicted later depression. 

practical applications for CBT

treatments like CBT which are based on cognitive theories are effective for many people. they aim to identify people’s negative and irrational thinking patterns and change them to more functional ones

negative of cognitive approach - limited

there are some aspects of depression that are not particularly well explained by cognitive explanations, e.g. some depressed people experience feelings of intense anger or even hallucinations and delusions. also, ellis’s theory only focuses on reactive depression, depression that happens after a life event, but it struggles to explain endogenous depression, where depression cannot be traced back to any particular event

• beck - explains patterns of cognition but cannot easily explain extremes of anger or hallucinations and delusions

• ellis - only explains reactive depression, not cases that do not follow an activating event (endogenous depression)

what is CBT

a psychological therapy that combines behavioural and cognitive approaches

how is homework used in these treatments

record positive experiences to use in therapy to demonstrate reality

cognitive therapy…

challenges beck’s negative triad

REBT…

challenges ellis’ abc model, extends it to abcde

d = dispute (challenging irrational thoughts)

1. empirical argument: showing that the client is factually mistaken

2. logical argument: showing that the client has drawn an unjustified conclusion

e = effect (outcome of the therapy)

supportive research for CBT - march et al. 2007

compared CBT to antidepressants and to a combination of both. the study used 327 adolescents. after 36 weeks, 81% of the CBT group, 81% of the antidepressant group and 86% of the CBT and antidepressant group were significantly improved

non-supporting evidence for CBT: cuijpers et al. 2013

conducted a meta-analysis of 115 studies examining the effects of CBT, compared with control groups, other psychotherapies, and pharmacotherapy (drugs). they found the mean effect size of 94 comparisons from 75 studies of CBT and control groups was 0.71. they did not find any indication that CBT was more or less effective than other psychotherapies or pharmacotherapy

non-supporting evidence for CBT: long-term

ali et al. 2017 assessed depression in 439 clients every month for 12 months following a course of CBT. 42% of the clients relapsed into depression within 6 months of ending treatment and 52% relapsed within a year

non-supporting evidence for CBT: not appropriate for everyone

not everyone wants to tackle their depression using CBT. some just want their symptoms gone as quickly and easily as possible and prefer medication. as it is an active therapy, severely depressed people may lack the motivation to attend this, and this lack of effort decreases the effectiveness of the treatment. survivors of trauma may wish to explore the origins of their symptoms; they would find the present-focus of CBT frustrating.

non-supporting evidence for CBT: client-therapist relationship

success may be due to therapist-client relationship rather than the therapy itself; may be social relief instead. so, counselling may be more appropriate/effective instead, a practice which is also more available.

what constitutes OCD

a disorder marked by uncontrollable and recurring thoughts (obsessions), repetitive and excessive behaviours (compulsions), or both

behavioural characteristics of OCD

• compulsions - repetitive behaviours or mental acts performed to reduce the anxiety caused by obsessions, even if they provide only temporary relief

• avoidance - attempting to reduce anxiety by keeping away from situations that trigger it

emotional characteristics of OCD

• anxiety - intense discomfort, distress, or fear triggered by obsessive thoughts. it drives the urge to perform compulsions in an attempt to relieve the distress, even though the relief is usually temporary

• accompanying depression - low mood and lack of enjoyment in activities

• guilt and disgust - irrational guilt, feeling one has done something wrong even when that is not the case. intense feelings of disgust, e.g., dirt. feelings of disgust against oneself are also possible

cognitive characteristics of OCD

• obsessions -persistent, recurring, unwanted, and distressing thoughts, images, or urges that cause anxiety

• cognitive coping strategies - mental technique used to manage stress, anxiety, or distressing thoughts, e.g. counting - silently or mentally counting in a structured way (e.g. counting to 10 or backward from 100) to refocus the mind and create a sense of control, or prayer or mantras - reciting a comforting prayer, affirmation, or mantra to provide reassurance and shift focus away from obsessive thoughts

• hypervigilance - constant alertness

• insight into excessive anxiety - awareness that obsessive thoughts are irrational and unrealistic

describe the cycle of OCD

the repeating pattern that maintains obsessive-compulsive disorder. it typically follows four stages:

1. obsession – an intrusive, distressing thought, image, or urge.

2. anxiety / distress – the obsession causes intense fear, anxiety, or discomfort.

3. compulsion – the person engages in a repetitive behaviour to relieve the anxiety.

4. temporary relief – the compulsion provides short-term relief, but the brain learns that the obsession was "dangerous" and that compulsions are necessary, reinforcing the cycle 

describe genetic explanations

genes make up chromosomes and consist of DNA which codes for the physical features of an organism and psychological features. genes are transmitted from parent to offspring

define genetic vulnerability

some people appear to be predisposed to develop OCD as a result of their genetic makeup

describe candidate genes for OCD

the specific genes likely to be involved in vulnerability

COMT gene - involved in production of dopamine

SERT gene - involved in transmission of serotonin

OCD is thought to be polygenic - not caused by a single gene but several

OCD is aetiologically heterogeneous

• different groups of genes may cause OCD in different genes

• different groups of genes cause different types of OCD

• different causes of OCD have been identified - multiple genes and the environment

define polygenic

230 different genetic variation may be involved in OCD

different genetic bases are involved in different types of OCD

define diathesis

vulnerability of predisposition to a certain condition

supporting research for OCD - twin studies; nestadt et al. 2010

reviewed twin studies, found that 68% of identical twins MZ both had a diagnosis of OCD as opposed to 31% of non-identical DZ twins. another source of evidence for a genetic influence on OCD comes from family studies. research has found that a person with a family member diagnosed with OCD is around 4x more likely to develop it as someone without

describe neural explanations

abnormal functioning of neurotransmitters and/or brain structures

describe decision-making systems

lateral frontal lobes responsible for logical thinking and making decisions; may be impaired or functioning abnormally with OCD due to disrupted serotonin system, physical damage to lobes or genetic mutations. linked to obsessions and compulsions

describe system involved in processing unpleasant emotions

parahippocampal gyrus; may function abnormally in OCD so unpleasantness is not reduced due to disrupted serotonin system, physical damage to lobes or genetic mutations

strength of neural explanations of OCD: research evidence

• PET scans show relatively low levels of serotonin activity in the brains of OCD patients

• saxena and rauch 2000 reviewed studies of OCD that used PET, fMRI and MRI neuro-imaging techniques. they found consistent evidence for an association between the orbital frontal cortex and OCD symptoms

weakness of neural explanations for OCD: methodology

• problems of cause and effect; correlation is supported however such correlations do not necessarily indicate a casual relationship - both may be influenced by a third factor or OCD causes the abnormal brain function rather than vice versa. neurochemical imbalances and structural abnormalities may be a symptom rather than the cause of the illness; no causation is proved.

strength of of neural explanations for OCD: application

• practical application in therapy: SSRIs - reduction in symptoms implies that it is an imbalance in serotonin that causes OCD.

• but - co-morbidity - is improvement due to improvement of depressive symptoms

basic effect of antidepressants

affect levels of nuerotransmitters e.g. serotonin

define combination treatment for OCD

SSRIs combined with psychological therapies like CBT (a type called exposure and response prevention) and with other drugs

alternatives to SSRIs

• tricyclics (which have more severe side effects) and SNRIs - increase levels of serotonin in the synapse

• anti-anxiety drugs enhance the activity of GABA and therefore slow down the CNS causing relaxation

• clomipramine

define drug therapy

treatment involving drugs e.g. chemicals that have a particular effect on the functioning of the brain or some other body system. in the case of psychological disorders such drugs usually effect neurotransmitter levels

define psychoactive drugs

chemical substances that alter one’s mental processes e.g. they act directly on the brain e.g. affecting synaptic transmission

describe SSRIs

• increase available amount of serotonin in the synapse by preventing their reabsorption by the transmitting neuron. serotonin therefore continues to stimulate the post-synaptic neuron, reducing brain activity. fluoxetine is an example - typical dosage is between 20 and 60 mg per day. active ingredients are delivered by capsule of liquid if the patient is hospitalised. they typically take 3 to 4 months to show an effect on OCD symptoms

• thought to work because if we assume that low levels of serotonin cause OCD symptoms, then increasing levels of serotonin should decrease the symptoms

• inhibit the reuptake of serotonin in the presynaptic neuron and therefore increase levels of serotonin in the synapse, alleviating the symptoms of depression, which is often caused by the anxiety resulting from OCD

evidence that drug treatment for OCD is effective/appropriate

• supported by meta-analysis of clinical trials (soomro et al 2008 - found that SSRIs were more effective than placebos in the treatment of OCD, in 17 different trials. symptoms reduced for about 70% of people taking SSRIs. the other 30% were improved with the use of other drug treatments)

• drugs are a cheap (for the NHS - cheaper than paying a clinical psychologist) easy, and quick option compared to psychological treatments

• drug trials include well controlled experiments, use of random allocation, placebos/control conditions and blind procedures so we can be confident about cause-and-effect conclusions e.g. drug causes recovery

evidence that drug treatment for OCD is not effective/appropriate

• there can be side effects that reduce compliance to medication

• do not provide coping mechanisms for future - when drugs are no longer being used, symptoms will return