Clinical psychology + mental health

Use of definitions in the field of mental health

Decide if a person is mentally healthy

All mental disorders are classified as:

Psychotic → severe detachment with reality + unaware of disorder ~ schizophrenia
Neurotic → milder + remain grasp on reality ~ OCD, depression

DSM IV

Diagnostic + statistical manual of mental disorders
Used to diagnose + classify mental health conditions

ICD

Globally recognised classification of diseases

Definitions in the field of mental health: statistical infrequency

Any relatively usual behaviour or characteristic can be thought of as normal, any behaviour that is different to this = abnormal

In any human characteristic → majority of people’s scores = cluster around average, further above or below that average → fewer people will attain that score = normal distribution
Example ~ intellectual disability disorder

Definitions in the field of mental health: statistical infrequency AO3

+ Real life application → can be applied to diagnose intellectual disability disorder ~ normal behaviour deviates from statistical norm (avg IQ) = abnormal + acts as a diagnosis for many mental health conditions

- Unusual characteristics can be positive → IQ above average = abnormal but it isn’t an undesirable characteristic that needs to be treated like low intelligence → abnormality cannot be used alone to make a diagnosis

- Not everyone unusual benefits from a label → labelled as abnormal = can lead to stigma, if they are happy and functioning why?

Definitions in the field of mental health: deviation from social + cultural norms

A person is abnormal if their behaviour is different from the accepted standards of behaviour in a community or society ~ personal space, manners

Example ~ antisocial personality disorder → DSM IV says an important symptom = absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behaviour

Definitions in the field of mental health: deviation from social + cultural norms AO3

+ Social norms vs statistical norms → social norms may be more useful = takes into account desirability ~ high IQ

- Not a sole explanation → unconventional behaviour may not always indicate a disorder ~ living in a campervan

- Human rights abuse → enables abuse of people cause they are different = saying it is ‘mental illness’ to control ~ homosexuality

- Cultural relativism → social norms may vary between generations + cultures = problematic as how do we decide?

Definitions in the field of mental health: failure to function adequately

Someone has a mental health condition when they can no longer cope with the demands of everyday life ~ unable to maintain basic standards of hygiene

Rosenhan + Seligmann signs to identify if someone is failing to function:

• No longer conforms to standard interpersonal rules ~ eye contact, respecting personal space

• Person experiences severe distress

• Behaviour becomes irrational or dangerous to themselves or others

Example ~ intellectual disability disorder

Definitions in the field of mental health: failure to function adequately AO3

+ Patients perspective → considers subjective experience of individual = identifies those people who need help, not by a statistic

- Misses some abnormal behaviours → fails to identify abnormal behaviours that do not cause personal distress ~ psychopathic criminal behaviour = individuals may function normally despite engaging in acts that are clearly abnormal + have a negative impact on others

- Subjective judgement → someone has to judge if a person is failing to function adequately, even with a scale used to assess functioning, a psychiatrist will be making their judgement = subjective to their opinion ~ Freud

Definitions in the field of mental health: deviation from ideal mental health

Focuses on what is ‘normal’ rather than abnormal
Jahoda came up with a set of criteria that a person must meet, deviation = mental health disorder

Jahoda’s criteria for good mental health + environmental mastery:

• No symptoms of distress

• Rational + can perceive self accurately

• Self actualisation

• Cope with stress

• Realistic view of world

• Good self-esteem + lack of guilt

• Independent of others

• Successfully work + love + enjoy leisure time

Definitions in the field of mental health: deviation from ideal mental health AO3

+ Comprehensive definition → covers a broad range of criteria = good tool vs stats

+ Real-life application → can be used as a basis for therapy + treatments = emphasising positive mental health + wellbeing
- Unrealistic? → very few people achieve all of Jahoda’s criteria = classified as having a mental health disorder

- Cultural relativism → ethnocentrism as criteria reflect Western individualistic values ~ autonomy = makes it less applicable to collectivist cultures that prioritise community = cannot be universalised

Phobias: definition

• Anxiety disorder characterised by extreme + irrational fear of a specific object or situation

• Fear = excessive or unreasonable

• Significantly interferes with individual’s daily life

Phobias: behavioural characteristics

• Avoidance → active effort to avoid phobic stimulus = can make daily life difficult

• Panic → in response to phobic stimulus ~ crying + screaming

Phobias: emotional characteristics

• Anxiety → intense + high state of arousal = prevents sufferer feeling relaxed + difficulty in experiencing positive emotions long term

• Irrationality → disproportionate fear in comparison to phobia ~ arachnophobia

Phobias: cognitive characteristics

• Attention = selective to phobic stimulus → find it difficult to not focus on phobic stimulus

• Distortions → perception of stimulus = exaggerated + irrational ~ arachnophobia

Phobias: behavioural approach to explaining phobias

Two process model → classical + operant conditioning

• Phobias → acquired = classical conditioning

  • Associate thing with negative feeling ~ fear + disgust

• Phobias → maintained = operant conditioning

  • Negative reinforcement → go out of way to avoid it

Phobias: behavioural approach to explaining phobias AO3

+ Explanatory power → explains how they are formed + maintained

+ Little Albert experiment → laboratory support for classical conditioning as reason for acquisition of phobia

- Alternative evolutionary explanation → Seligman suggests humans have a predisposed biological preparedness to develop certain phobias rather than others = adaptive in our evolutionary past ~ avoid snakes + high places = more likely to survive + pass on genes

- Ignores cognitive factors → argue the mental processes that occur between stimulus + response = responsible for the feeling component of the response

Phobias: behavioural approach to treating phobias

• Aim = replace learned fear association with new + more positive association ~ relaxation

• Process = counter-conditioning

• Relies on principle of reciprocal inhibition → two opposite emotional states ~ fear + relaxation, cannot coexist simultaneously

Phobias: behavioural approach to treating phobias → systemic desensitisation

Gradual behavioural therapy = reduce phobic anxiety → step-by-step exposure to phobic stimulus.

Three key components:

• Relaxation → patient is taught deep muscle relaxation techniques ~ breathing exercises or progressive muscle relaxation.

  • The goal = reduce the activity of the sympathetic nervous system (fight-or-flight response) + activate the parasympathetic nervous system

• Anxiety hierarchy → patient + therapist create a step-by-step list of situations involving phobic stimulus

  • Ordered from least anxiety-provoking → most terrifying

• Gradual exposure → patient gradually works up anxiety hierarchy over several sessions

  • Applying learned relaxation techniques at each stage

  • Phobia = considered cured → patient can remain calm at highest level of hierarchy

Phobias: behavioural approach to treating phobias → systemic desensitisation AO3

+ Effective supported by research → Gilroy et al

• Followed up 42 patients who had been treated for arachnophobia in three 45 minute sessions of SD vs control group who were treated with relaxation without exposure

• Assessed by questionnaire

• At both 3 months, then 33 months after treatment → SD group = less fearful vs relaxation group

• Treatment = helpful + long lasting

+ Suitable for diverse range of patients

• Can go at own pace + less traumatic → vs flooding

• Approaches issue head on → vs cognitive therapies

• Suitable for those with learning difficulties → does not require complex cognitive engagement

- Time consuming

Phobias: behavioural approach to treating phobias → flooding

Exposing patient to most feared phobic stimulus immediately + intensely → without any gradual build-up or avoidance options

• Exposure occurs in a safe + controlled environment from which the patient cannot escape

• Underlying principle of flooding = fear is a time-limited response.

• Initially → patient experiences extreme anxiety + panic

• However as phobic object or situation ≠ harmful + escape or avoidance = prevented → patient’s anxiety cannot be maintained indefinitely + will eventually subside due to exhaustion

• Leads to extinction of phobia → conditioned stimulus no longer produces conditioned response of fear

Phobias: behavioural approach to treating phobias → flooding AO3

+ Cost effective + time efficient → requires less time + resources than SD

+ Effective → for those who can complete the treatment = rapid reduction of phobic anxiety

- Not suitable for all → children or patients with underlying medical conditions ~ heart diseases = creates such heightened anxiety

- Traumatic → causes significant emotional distress

- Risk of reinforcing phobia → if flooding is not conducted properly = can reinforce phobia + make it worse

• Wolpe reported a case where flooding led to a client’s hospitalisation

Depression: definition

• Mood or affective disorder

• Characterised by continuous state of sadness + low mood

• Characteristics are severe + prolonged = damaging to everyday functioning

Depression: behavioural characteristics

• Level of activity → lethargy or psychomotor agitation (~ leg shaking)

• Disruption to sleep → reduced or interrupted sleep = insomnia, or need for more sleep = hypersomnia

Depression: emotional characteristics

• Low self esteem → low view of self leading to excessive guilt, feeling hopeless ~ extreme self loathing

• Anger → directed towards self + others ~ can lead to self harm

Depression: cognitive characteristics

• Concentration → inability to stick with task + find it hard to make decisions they would normally make

• Negative thoughts → obsess over negative aspects of situation + ignore positives ~ focus on one D grade, despite rest being As

Depression: cognitive approach to explaining depression

• Internal mental processes → especially negative + distorted + irrational thinking + misinterpretation of events = primary cause of emotional + behavioural problems like depression

• May cause maladaptive (negative) behaviour

• Way you think about problem > problem itself

Depression: cognitive approach to explaining depression → Beck’s theory

(schemas)

• Suggested cognitive vulnerability: three parts

1. Faulty info processing = fundamental errors in logic

• Selectively focus on negative aspects of situation + ignore positive aspects

• Think in black & white + blow small problems out of proportion

2. Negative self schemas = mental framework developed with experience about self

• Those with depression = developed negative self schemas → interpret all info about self negatively

• Weissman + Beck study

3. Negative triad = schema of tendency to view self + world + future = negatively

• Built on idea of maladaptive responses → trapped in cycle of negative thoughts

Depression: cognitive approach to explaining depression → Weissman + Beck study

A → investigate thought processes of depressed people → establish whether it is a result of negative schemas

P → thought processes measured using DAS (dysfunctional attitude scale), ppts filled out questionnaire agreeing or disagreeing with set of statements ~ ‘people will probably think less of me if I make a mistake’

F → depressed ppts > non-depressed ppts chose more negative assessments + when given some therapy to challenge + change negative schemas = improvement in self ratings

C → depression involves the use of negative schemas

C → self-report techniques used

Depression: cognitive approach to explaining depression → Beck’s theory AO3

+ Weissman + Beck study → supports idea of negative schemas as a root of depression

+ Practical application → Beck’s cognitive explanation forms basis of CBT

- Not a comprehensive explanation → explains basic symptoms, but not all symptoms + complex symptoms ~ fatigue

Depression: cognitive approach to explaining depression → Ellis’ theory

(irrational)

• Suggested good mental health = result of rational thinking

• There are common irrational beliefs that underlie much depression → sufferers base their lives on these beliefs

• ABC model:

  • Activating event (causes)

  • Belief (which results in)

  • Consequence

• Beliefs subject to cognitive biases (like Beck suggests) → can cause irrational thinking = undesirable behaviours

• Irrational beliefs make impossible demands on individual

Depression: cognitive approach to explaining depression → Ellis’ theory AO3

+ Practical application → Ellis’ theory led to successful therapy ~ REBT, by challenging irrational negative beliefs

- Not a comprehensive explanation → some depression occurs as a result of an activating event, but not all depression arises from obvious cause

- Cannot explain all aspects of depression → why some experience anger associated with depression

Depression: cognitive approach to explaining depression → Newark et al (Ellis’ theory)

A → investigate if people with psychological problems = had irrational attitudes

P → Two groups of ppts = diagnosed with anxiety vs control → asked if they agreed with statements identified by Ellis as irrational ~ one must be perfectly competent + adequate + achieving in order to consider oneself worthwhile

F → 85% of anxious ppts agreed with statement vs 25% of non-anxious ppts

C → people with emotional problems = think in irrational ways

C → self-report techniques

Depression: cognitive approach to explaining depression → AO3 alternate explanation

• Reductionist → ignores biological factors + success of drug therapies

• Should use interactionist approach

Depression: cognitive approach to treating depression → CBT

• Most common method → based on both behavioural + cognitive techniques

• Psychotherapy ~ thoughts about self + world + others, how behaviour affects thoughts + feelings

• Aims to deal with negative thoughts → break vicious circle of maladaptive thinking + feelings + behaviour

  • Focus on here & now > past

• Therapist aims to make client aware of relationship between thought + emotion + actions

  • Equip client to deal with it themselves

• Behavioural activation → encourage patients to engage in activities they avoid

• Helps change thoughts (cognition) + what they do (behaviour) = help them feel better

Depression: cognitive approach to treating depression → Beck’s CBT

• Challenge negative triad of client

1. Client is assessed → discover severity of condition

2. Therapist establish baseline to help monitor improvement

• Use process of reality testing → challenge beliefs = irrational ideas can be replaced with more optimistic + rational beliefs

Depression: cognitive approach to treating depression → Ellis’ REBT

• Rational emotive behaviour therapy

• ABCDE model → activating events, beliefs, consequences, disputing beliefs, effect

• Identify + dispute irrational thoughts = empirical disputing

• Types of disputes = shame attacking

  • Empirical arguments ~ consistent with reality

  • Logical arguments ~ logically follow you can rate whole self based on one part

  • Pragmatic arguments ~ consequences of belief

• Based on premise beliefs we hold = causes depression, not event itself

Depression: cognitive approach to treating depression → CBT AO3

+ Effective → reduces symptoms of depression + preventing relapse = lots of evidence ~ March et al, Fava et al found it is as effective as antidepressants

- Interactionist approach → Keller et al found 85% recovery rate from depression when using CBT + drugs vs 55% drugs alone, 52% CBT alone

- Success may be due to therapist-patient relationship

- Cannot be sole treatment → some cases patients cannot motivate themselves to engage in therapy so must be treated with antidepressants first

OCD: definition

Unwanted thoughts (obsessions) that lead to repetitive behaviours (compulsions)

OCD: behavioural characteristics

• Compulsions → repetitive behaviours that ‘reduce’ the anxiety produced by obsessions

• Avoidance → keeping away from situations to reduce anxiety

• Both can affect day to day suffering

OCD: emotional characteristics

• Anxiety + distress → obsessions = unpleasant + frightening + overwhelming

• Guilt → sometimes have irrational guilt

OCD: cognitive characteristics

• Obsessive thoughts → unpleasant obsessive thoughts = major cognitive feature for 90% of sufferers

• Cognitive strategies → people respond to obsessive thoughts by having coping strategies ~ religious person may feel guilt then pray (could affect functioning)

OCD: biological approach to explaining OCD → genetic explanations (diathesis model)

Diathesis model → biological predispositions + environment work together = affect brain = mental conditions

• Diathesis = vulnerability to mental illness ~ possess genes linked to OCD but not have illness, only a vulnerability

• Interactionist approach

• Mental illness = stress x diathesis

1. Diathesis → vulnerability that is a predisposition genetically

2. Stressors → environmental + emotional + physical

3. Protective factors → provide a buffer between mental illness ~ loving family + friends

OCD: biological approach to explaining OCD → genetic explanations (candidate genes)

(gene does not = cause of OCD, causes other factors that may biologically cause OCD)

Candidate genes = genes identified to create vulnerability for OCD

• COMT gene → linked to dopamine = reward chemical ~ compulsions

  • Involved in production of COMT

  • COMT regulates production of dopamine → linked to OCD

  • One form of COMT → found more common in individuals with OCD vs without

  • Variation of gene produces lower activity of COMT gene + higher levels of dopamine (Tukel et al)

• SERT gene → linked to serotonin = mood stabiliser ~ obsessive thoughts (particularly negative)

  • Serotonin transporter

  • SERT gene affects transport of serotonin = lower levels of serotonin

  • Lower levels of serotonin = linked to OCD

  • Mutation of gene in two separate families → 6/7 family members had OCD (Ozaki et al)

OCD: biological approach to explaining OCD → genetic explanations (polygenic)

• Several genes = involved in OCD

• Taylor → analysed findings of previous studies = found evidence that up to 230 genes may be involved in OCD

• Genes related to mood regulating neurotransmitters ~ dopamine + serotonin have been studied in relation to OCD

OCD: biological approach to explaining OCD → genetic explanations (varying types)

• OCD → aetiologically heterogenous = different groups of genes may cause OCD in different people

• Some evidence suggests different types of OCD may be the result of particular genetic variations ~ hoarding, religious obsession

OCD: biological approach to explaining OCD → genetic explanations AO3

+ Research support → Lewis

• 37% of OCD patients had parents with OCD + 21% had siblings with OCD

• Suggests OCD is a genetic vulnerability that is passed on through generations

+ Research support → Nestadt et al

• Twin studies → reviewed twin studies → found 68% of MZ twins had OCD vs 31% of DZ twins

• Counter → twin studies = flawed evidence, usually very similar environments = genes or environment?

- Too many candidate genes → unsuccessful in narrowing down genes involved + several genes involved = cannot make predictions based on a genetic explanation

- Environmental risk factors → cannot be entirely genetic

• Cromer et al → > 50% OCD patients had a traumatic event in past + OCD = more severe in those with more than one trauma

• OCD likely has environmental factors → not entirely genetic

OCD: biological approach to explaining OCD → neural explanations

• Genes associated with OCD = likely to affect levels of key neurotransmitters + neural brain structures

OCD: biological approach to explaining OCD → neural explanations (role of serotonin)

• Serotonin = neurotransmitter linked to regulating mood

• Neurotransmitter = relays info from one neuron to another

• Low levels of serotonin = below normal levels of mood-relevant info transmitted → affects mood + other mental processes

• Some cases of OCD may be explained by a reduction in functioning of serotonin system in brain = affects obsessive thoughts + low mood

OCD: biological approach to explaining OCD → neural explanations (decision making structures)

• Based on idea some OCD sub-types are linked to poor decision making ~ hoarding disorder

• Poor decision making may = abnormal functioning of lateral frontal lobes of brain → responsible for logical thinking + decision making (under working)

• Evidence suggests left parahippocampal gyrus may function abnormally in people with OCD → associated with processing unpleasant emotions (working overtime)

OCD: biological approach to explaining OCD → neural explanations AO3

+ Supporting research → some antidepressants work purely on serotonin system → reduce OCD symptoms = suggests serotonin system is involved in OCD

- Research is only correlational → only links parts of brain to OCD, not a clear cause and effect

- Not clear which exact neural mechanisms are involved → studies have shown neural systems for decision making are the same systems that function abnormally in OCD ~ Cavedini

• But other research identified other brain systems = difficult to understand which neural systems are actually involved in OCD

- Neural mechanisms = OCD vs OCD = neural mechanisms → neural abnormalities may be a result of OCD, rather than the cause

OCD: biological approach to treating OCD → drug therapy (SSRIs)

Selective serotonin reuptake inhibitor

• Serotonin released by certain neurons → released by pre-synaptic → travels along synapse → chemically conveys signal from pre to post-synaptic neuron → reabsorbed by pre-synaptic neuron + broken down + re-used

• SSRIs prevent reabsorption + breakdown of serotonin = increases level of serotonin in synapse → can continue to stimulate post-synaptic neuron

• Compensates for fault in serotonin system in OCD sufferers

• ~ fluoxetine, sertraline

OCD: biological approach to treating OCD → drug therapy (alternatives to SSRIs)

• Tricyclics

  • Same effect on serotonin absorption as SSRIs

  • More severe side effects = prescribed to patients who do not respond to SSRIs

  • ~ clomipramine

• SNRIs

  • Serotonin noradrenaline reuptake inhibitors

  • Increase serotonin + noradrenaline (neurotransmitter) levels

  • Used for those who do not respond to SSRIs

• Interactionist approach → drugs + CBT

OCD: biological approach to treating OCD → drug therapy AO3

+ Research support → Soomro et al

• Reviewed studies comparing SSRIs to placebos in treatment of OCD → concluded all 17 studies showed significantly better results for SSRIs > placebo conditions

+ Statistics → research has shown 70% decline in OCD symptoms for those who use drug therapy

+ Cheap + non-disruptive to NHS

- Side effects ~ insomnia, headaches, loss of sex drive → not suitable for everyone

Alternative interactionist approach → drug therapy alongside psychotherapy