PSYCHOPATHOLOGY

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drug therapy
treatment involving drugs, i.e. chemicals that have a particular effect on the functioning of the brain or some other body system - affect neurotransmitter levels
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how do SSRIs work?
* work on the serotonin system
* prevent reabsorption and breakdown of serotonin by the presynaptic neuron, SSRIs increase levels of serotonin in the synapse and continue to stimulate the postsynaptic neuron → compensates for what is wrong with the serotonin system in OCD
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how does the serotonin system work?
* serotonin is released by presynaptic neurons and travel across a synapse.


* the neurotransmitter chemically conveys the signal from the presynaptic neuron to the postsynaptic neuron.
* it is then reabsorbed by the presynaptic neuron where it is broken down and reused
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what is the biological approach to treating OCD?
involves an antidepressant drug called a selective serotonin reuptake inhibitor
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what is the dosage of SSRIs for OCD?
vary according to which is prescribed. typical dose of *fluoxetine* is 20mg but may be increased if it is not benefitting the person. takes 3/4 months of daily use to have an impact
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combining SSRIs with other treatments
drugs are used alongside CBT to treat OCD → drugs reduce emotional symptoms so people with OCD can engage more effectively with the CBT- some respond best to CBT/drugs alone
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tricyclics
* older antidepressant (clomipramine)
* acts on various systems including the serotonin system - same effect as SSRIs
* more severe side-effects - kept in reserve
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when should you try alternatives to SSRIs?
when an SSRI is not effective after 3-4 months the dose can be increased or combined with other drugs - sometimes different antidepressants are tried
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SNRIs
* serotonin-noradrenaline reuptake inhibitors
* different class of antidepressant drugs and are a second line of defence for people who don’t respond to SSRIs
* increase serotonin and noradrenaline levels
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strength of biological approach to treating OCD: evidence of effectiveness
* clear evidence showing SSRIs reduce symptom severity and improve quality of life for people with OCD
* Soomro: reviewed 17 studies comparing SSRIs to placebos in treatment of OCD
* all 17 showed better outcomes for SSRIs than placebo conditions
* symptoms reduce for around 70% of people taking SSRIs. remaining 30% = helped by alternative drugs, combinations or therapies
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counterpoint of biological approach to treating OCD
* evidence to suggest even if drugs are helpful for most they may not be most effective available
* Skapinakis *et al*: systematic review of outcome studies and concluded both cognitive and behavioural therapies were more effective than SSRIs
* drugs not optimum treatment for OCD
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strength of biological approach to treating OCD: cost-effective and non-disruptive
* drug treatments are cheap compared to psychological treatments
* many thousands of tablets can be manufactured in the time it takes to conduct one session of a psychological therapy
* drugs are good value for public health systems like the NHS and represents a good use of limited funds
* SSRIs are non-disruptive to people’s lives - take drugs and symptoms decline - different from therapy involving time spent attending sessions
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limitation of biological approach to treating OCD: serious side-effects
* small minority will get no benefit from SSRIS
* side effects such as indigestion, blurred vision and loss of sex-drive
* usually temporary but can be distressing for people and a minority are long lasting
* those taking clomipramine: side-effects are more common and more serious
* > 1 in 10 experience erection problems and weight gain, 1 in 100 become aggressive and have heart-related problems
* reduced quality of life. may stop taking them = drug not effective
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genetic explanations
genes make up chromosomes and consist of DNA which codes the physical features of an organism and psychological features - transmitted from parents to offspring
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neural explanations
the view that psychological characteristics are determined by the behaviour of the nervous system
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candidate genes in OCD
researchers have identified genes which create a vulnerability for OCD which involve regulating the development of the serotonin system → the gene **5HT1-D beta** is implicated in the transport of serotonin across synapses
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how is OCD polygenic?
OCD is not caused by one single gene but a combination of genetic variations that increase vulnerability
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Taylor
analysed findings of previous studies and found evidence that up to 230 different genes may be involved in OCD - associated with the action of dopamine and serotonin
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how is OCD aetiologically heterogeneous?
the origins of OCD vary from one person to another. also evidence to suggest different types of OCD may be the result of particular genetic variations (hoarding disorder)
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how are genes involved in individual vulnerability to OCD?
Lewis observed that of his OCD patients, 37% had parents with OCD and 21% had siblings with OCD - suggests genetic vulnerability is passed on from one generation to the next
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diathesis-stress model for OCD
certain genes leave some people more likely to develop a mental disorder but it is not certain - some environmental stress is necessary to trigger the condition
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role of serotonin in OCD
neurotransmitters are responsible for relaying information from one neuron to another - low levels of serotonin means normal transmission of mood-relevant info doesn’t take place and person may experience low moods
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decision making systems in OCD
abnormal functioning of the lateral and frontal lobes of the brain may be associated with impaired decision making (hoarding disorder). they are responsible for logical thinking and making decisions
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parahippocampal gyrus in OCD
associated with processing unpleasant and functions abnormally in OCD
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strength of genetic explanation of OCD: research support
* evidence suggests people are vulnerable to OCD as a result of their genetic make-up
* Nestadt *et al:* reviewed twin studies and found 68% of identical twins shared OCD opposed to 31% of non-identical twins
* family studies: a person with a family member diagnosed with OCD is 4x more likely to develop it as someone without
* genetic influence for OCD
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limitation of genetic explanation for OCD: environmental risk factors
* evidence that genetic variation makes a person more or less vulnerable to OCD
* OCD doesn’t actually appear entirely genetic in origin, seems environmental risk factors can also trigger or increase the risk of developing OCD
* Cromer *et al:* over half the OCD clients in their sample had experienced a traumatic event in their past
* OCD more severe in those with 1+ traumas
* genetic vulnerability is a partial explanation
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strength of neural explanation for OCD: research support
* antidepressants that work purely on serotonin are effective in reducing OCD symptoms - suggests serotonin may be involved in OCD
* OCD symptoms for parts of conditions that are known to be biological in origin
* e.g. Parkinson’s disease, causes muscle tremors and paralysis
* if a biological disorder produces OCD symptoms we assume the biological processes underlie OCD
* biological factors may also be responsible for OCD
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limitation of neural explanation of OCD: no unique neural system
* serotonin-OCD may not be unique to OCD
* many with OCD also have clinical depression - co-morbidity
* this depression involves disruption to the action of serotonin
* logical problem when serotonin is a possible basis of OCD
* serotonin activity may be disrupted in people with OCD because they are depressed as well.
* serotonin not relevant
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irrational thoughts
defined as thoughts that are likely to interfere with a person’s happiness → lead to mental disorders such as depression
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what is the cognitive approach to treating depression?
cognitive behavioural therapy (Becks CBT and Ellis’ REBT)
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cognitive behavioural therapy
**cognitive elements:** assessment where the client and therapist work together to clarify client’s problems - identify goals for therapy and create a plan. identify irrational thoughts that will benefit from challenge

**behavioural element:** working to change negative and irrational thoughts and put more effective behaviours into place
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Beck’s cognitive therapy
* identify automatic thoughts about the world, the self and the future - the negative triad - once identified they can be challenged
* test the reality/validity of negative beliefs
* ‘client as scientist’- set HW like recording when they enjoyed an event - investigating negative beliefs
* therapist can produce evidence and use it to prove client’s statements as incorrect
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Ellis’ REBT
* rational emotive behaviour therapy extends ABC model to include Dispute and Effect
* main technique is to identify and dispute irrational thoughts
* therapist challenges irrational beliefs through vigorous argument - intended to change the irrational belief and break the link between negative life events and depression
* different methods of dispute: **empirical argument** (disputing whether there is actual evidence to support the belief) and **logical argument** (disputing whether negative thought logically follows from the facts)
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behavioural activation
Both cognitive therapies involve behavioural activation - when a patient is encouraged to ‘activate’ positive behaviours to help lift them out of their depression e.g. exercise, or socialising with close friends. (increased engagement improves mood)
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strength of cognitive approach to treating depression: evidence for effectiveness
* studies show CBT works
* March *et al:* compared CBT to antidepressants and to a combination of both treatments when treating 327 depressed teens
* after 36 weeks, 81% of CBT group, 81% of antidepressants group and 86% of combined group were significantly improves
* CBT just as effective when used on its own and more so when used alongside antidepressants
* CBT is brief - requiring 6-12 sessions so it’s cost effective
* first choice of treatment for NHS
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limitation of cognitive approach to treating depression: suitability for diverse clients
* some cases of depression are so severe clients can’t motivate themselves to engage with the cognitive work of CBT
* may not pay attention to what is happening
* complex rational thinking involved in CBT makes it unsuitable for treating depression in clients with learning disabilities
* Sturmey: any form of psychotherapy is not suitable for people with learning disabilities, in CBT
* CBT only appropriate for a specific range of people
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counterpoint of cognitive approach to treating depression
* conventional wisdom: CBT is unsuitable for very depressed people and learning disabilities
* recent evidence challenges this
* Lewis and Lewis: concluded CBT was as effective as antidepressant drugs and behavioural therapies for severe depression
* Taylor: when used appropriately CBT is effective for people with learning disabilities
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limitation of cognitive approach to treating depression: relapse rates
* high relapse rates
* CBT is effective in tackling symptoms of depression bu there are concerns over how long benefits last
* few studies of CBT for depression looked at long-term effectiveness
* recent studies show long term outcomes aren’t as good
* Ali: assessed depression in 439 clients every month for 12 months following a course of CBT
* 42% relapsed within 6 months of ending treatment and 53% relapsed within a year
* CBT to be repeated
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cognitive approach
focused on how our mental processes affect behaviour
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Beck
took a cognitive approach to explaining why some are more vulnerable to depression than others - is a person’s cognitions that create this vulnerability. beck suggested 3 parts to this cognitive vulnerability (faulty info processing, negative self-schema, negative triad)
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faulty information processing
when depressed people attend to the negative aspects of a situation and ignore positives - tend towards ‘black and white thinking’ where something is either all bad or all good
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negative self-schema
a self-schema is the package of information people have about themselves - if a person has a negative-self schema they interpret all information about themselves in a negative way
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the negative triad
beck suggested a person develops a dysfunctional view of them selves because of three types of negative thinking that occur automatically regardless of reality


1. negative view of the world (no hope anywhere)
2. negative view of the future (reduce hopefulness and enhance depression)
3. negative view of the self (confirm low self-esteem)
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Ellis
proposed good mental health is the result of rational thinking, thinking in ways that allow people to be happy and free from pain. conditions like anxiety and depression result from irrational thought (thoughts that interfere with us being happy and free from pain). used the ABC model to explain
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Ellis’ ABC model
A - **Activating event** (irrational thoughts are triggered by external events - we get depressed when we experience negative events that trigger irrational beliefs)

B - **Beliefs** (musturbation: belief that it’s a major disaster whenever something doesn’t go smoothly, utopianism: belief that life is always meant to be fair)

C - **Consequences** (when activating event triggers irrational beliefs there are emotional and behavioural consequences)
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strength of Beck’s negative triad: research support
* ‘cognitive vulnerability’ = ways of thinking that may predispose a person to becoming depressed
* Clark and Beck: not only were these cognitive vulnerabilities more common in depressed people but they preceded the depression
* Cohen confirmed: tracked development of 473 teens, regularly measuring cognitive vulnerability
* found that showing cognitive vulnerability predicted later depression
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strength of Beck’s negative triad: real world application
* applications in screening and treatment of depression
* Cohen et al: assessing cognitive vulnerability allows psychologists to screen young people, identifying those most at risk of developing depression and monitoring
* understanding cognitive vulnerability is applied to CBT
* therapies work by altering kind of cognitions that make people vulnerable to depression - more resilient to negative life events
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strength of Ellis’ ABC model: real world application
* Ellis’ ABC model led to the creation of REBT
* idea of REBT is that by vigorously arguing with a depressed person, the therapist can alter the irrational beliefs that are making them unhappy
* some evidence to support the idea REBT can both change negative beliefs and relieve symptoms of depression
* real work value
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limitation of Ellis’ ABC model: reactive and endogenous depression
* ABC model only explains reactive depression not endogenous depression
* no doubt depression is often triggered by life events - reactive depression
* how we respond to negative life events also seems to be partly the result of our beliefs
* many cases of depression aren’t traceable to life events and it’s not obvious what leads the person to become depressed at a particular time - endogenous depression
* only a partial explanation
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systematic desensitisation
behavioural therapy designed to gradually reduce phobic anxiety through the principle of classical conditioning - if a person can learn to relax in the presence of the phobic stimulus they will be cured
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counterconditioning
learning of a new response to a phobic stimulus (stimulus is paired with relaxation instead of anxiety)
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what are the 3 processes in systematic desensitisation?
anxiety hierarchy, relaxation, exposure
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anxiety hierarchy
a list of situations related to the phobic stimulus that provoke anxiety arranged in order from least to most frightening - put together by a client and therapist. it’s
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relaxation
* therapist teaches the client to relax as deeply as possible - impossible to be afraid and relaxed at the same time, so one emotion prevents the other (reciprocal inhibition)
* involves breathing or mental imagery techniques or relaxation drugs
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exposure
* client is exposed to the phobic stimulus while in a relaxed state - takes place across several sessions, starting at the bottom of the anxiety hierarch. when client can stay relaxed in the presence of the phobic stimulus they move up the hierarchy
* treatment is successful when the client can stay relaxed in situations high on the anxiety hierarchy
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flooding
involves exposing people with a phobia to their phobic stimulus without a gradual build up - involves immediate exposure. longer than SD sessions but less sessions are needed
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how does flooding work?
stops phobic responses quick as the client quickly learns the phobic stimulus is harmless

extinction = learned response is extinguished when the conditioned stimulus is encountered without the unconditioned stimulus so conditioned stimulus no longer produces the conditioned response

client may achieve relaxation in the presence of the phobic stimulus because they become exhausted of their own fear response
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ethical safeguards of flooding
flooding is an unpleasant experience so it is important clients give fully informed consent to this procedure and that they are fully prepared before the session
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strength of SD for treating phobias: evidence of effectiveness
* Gilroy: followed up 42 people who had SD for spider phobia in three 45 minute sessions
* at both 3 and 33 months, the SD group were less fearful than a control group treated by relaxation without exposure
* Wechsler et al: concluded that SD is effective is for specific phobia, social phobia and agoraphobia
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strength of SD for treating phobias: people with learning disabilities
* some people requiring treatment for phobias also have a learning disability
* main alternatives to SD are not suitable
* people with LD struggle with cognitive therapies that require complex rational thought
* they may feel confused and distressed by the traumatic experience of flooding
* SD is most appropriate for people with LD
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strength of flooding to treating phobias: cost-effective
* clinical effectiveness means how effective a therapy is at tackling symptoms
* NHS needs to think about how much they cost
* a therapy is cost-effective if it is clinically effective and not expensive
* flooding can work in as little as one session as opposed to 10 of SD.
* allowing a longer session makes flooding more cost effective
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limitation of flooding for treating phobias: traumatic
* confronting phobic stimuli in an extreme form provokes tremendous anxiety
* Schumacher: found ppts and therapists rated flooding significantly more stressful than SD
* = ethical issue for psychologists knowingly causing stress to their clients,
* not as serious if they obtain informed consent
* traumatic nature of flooding means dropout rates are higher than for SD
* therapists may avoid this treatment
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Mowrer
proposed the two-process model based on the behavioural approach to phobias - states that phobias are acquired by classical conditioning and continue because of operant conditioning
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classical conditioning
learning by association - when two stimuli are repeatedly paired together - and unconditioned stimulus and a neutral stimulus. the neutral stimulus eventually produces the same response that was first produced by the unconditioned stimulus alone
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operant conditioning
a form of learning when behaviour is shaped and maintained by its consequences - positive/negative reinforcement or punishment
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Watson and Rayner
created a phobia in a 9 month old baby ‘Little Albert’

* when shown a white rat he tried to play with it
* but when experimenters wanted to create a phobia they made a loud frightening sound whenever the rat was presented to Albert
* Noise = UCS creates an UCR of fear.
* when rat and UCS are paired together, the NS becomes associated with the UCS and both produce the fear response
* Albert displayed fear when he saw the rat.
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how was conditioning generalised in Watson and Rayner’s study?
they tested Albert by showing him other furry objects such as a non-white rabbit, fur coat, and Santa Claus beard - he displayed distress at the sight of all of these
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classical conditioning process
neutral stimulus → no response

unconditioned stimulus → unconditioned response

neutral stimulus + unconditioned stimulus → unconditioned response

conditioned stimulus → conditioned response
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maintenance of phobias through operant conditioning
* phobias are long lasting as a result of OC
* takes place when our behaviour is reinforced or punished.
* Reinforcement increases the frequency of behaviour.
* In negative reinforcement - an individual avoids a situation that is unpleasant - results in a desirable consequence, which means the behaviour will be repeated.
* whenever we avoid a phobic stimulus we escape the fear and anxiety we would have experienced if we remained there → reduction in fear reinforced avoidance behaviour
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strength of behavioural approach to phobias: real world explanation
* used in exposure therapies
* distinctive element is that phobias are maintained by avoidance of phobic stimulus
* important in why people with phobias benefit from exposure to phobic stimulus
* once avoidance behaviour is prevented it stops being reinforced by the experience of anxiety reduction
* avoidance declines - phobia is the avoidance bhv so when avoidance is prevented the phobia is cured
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limitation of the behavioural approach to phobias: cognitive aspects
* behavioural explanations explain behaviour
* in phobias the key bhv is avoidance of phobic stimulus
* but phobias aren’t simply avoidance responses - also have a significant cognitive component
* people hold irrational beliefs about phobic stimulus
* two process model explains avoidance bhv but doesn’t explain phobic cognitions
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strength of behavioural approach to phobias: phobias and traumatic experiences
* evidence for a link between bad experiences and phobias
* little albert study shows how a frightening experience involving a stimulus can lead to a phobia
* systematic evidence from De Jongh et at: found 73% of people with a fear of dental treatment had experiences a traumatic experience either involving dentistry or violent crime
* compared to a control group of people with low dental anxiety - only 21% experienced a traumatic event
* confirms association between stimulus and UCR leads to phobia
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counterpoint of behavioural approach to phobias
* not all phobias appear after a bad experience
* common phobias such as snakes occur in populations where very few have any experience of snakes, let along traumatic experiences
* not all frightening experiences lead to phobias
* link between phobias and frightening experiences is not as strong as we would expect
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OCD
a condition characterised by obsessions/compulsive behaviour - obsessions are cognitive, compulsions are behavioural
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DSM-5 categories of OCD
* OCD (obsessive thoughts or compulsions)
* trichotillomania (compulsive hair pulling)
* hoarding disorder (compulsive gathering of possessions and inability to part with anything)
* excoriation disorder (compulsive skin-picking)
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emotional characteristics of OCD
* **anxiety and distress** (powerful anxiety accompanies obsessions and compulsions → obsessive thoughts are unpleasant and urge to repeat a behaviour creates anxiety)
* **depression** (anxiety can be accompanied by low mood and lack of enjoyment in activities)
* **guilt and disgust** (negative emotions like irrational guilt or disgust that’s directed at something external like dirt or the self)
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cognitive characteristics of OCD
* **obsessive thoughts** (affect 90% of people with OCD - thoughts that recur over and over again. vary but are always unpleasant)
* **cognitive coping strategies** (people respond to obsessions by adopting coping strategies to manage anxiety - can make person appear abnormal)
* **insight into excessive anxiety** (are aware their obsessions/compulsions aren’t rational but they experience catastrophic thoughts about the worse case scenarios that may result of anxieties were justified - hypervigilant)
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behavioural characteristics of OCD
* **compulsions are repetitive** (feel compelled to repeat a bhv, e.g. handwashing)
* **compulsions reduce anxiety** (10% show compulsive bhv alone. for most compulsive bhv is performed in an attempt to manage the anxiety produced by obsessions)
* **avoidance** (avoidance as they attempt to reduce anxiety by keeping away from situations that trigger it - can lead to avoidance of ordinary situations)
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phobia
an excessive fear and anxiety triggered by an object, place or situation - extent of fear is out of proportion to any real danger presented by phobic stimulus
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DSM-5 categories of phobia
* specific phobia (of an object or situation)
* social anxiety (phobia of social situations)
* agoraphobia (phobia of being outside/in a public place)
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behavioural characteristics of phobias
* **panic** (in presence of phobic stimulus, involves crying, screaming, running away, tantrum)
* **avoidance** (tend to go to a lot of effort to prevent coming into contact with the phobic stimulus = hard to go about daily life + interfere with work, education and social life)
* **endurance** (when a person chooses to remain in the presence of the phobic stimulus)
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emotional characteristics of phobias
* **anxiety** (involve an emotional response of anxiety - unpleasant state of high arousal preventing a person relaxing/experience positive emotion)
* **fear** (immediate and unpleasant response we experience when we encounter or think about a phobic stimulus - more intense)
* **emotional response is unreasonable** (anxiety/fear is greater than normal and disproportionate to any threat posed)
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cognitive characteristics of phobias
* **selective attention to phobic stimulus** (if phobic stimulus is present it is hard to look away from - gives best change of reacting quickly to a threat)
* **irrational beliefs** (thoughts that can’t be explained and don’t have any basis in reality in relation to phobic stimuli)
* **cognitive distortions** (perceptions may be inaccurate and unrealistic)
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depression
a mental disorder characterised by low mood and low energy levels
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DSM-5 categories of depression
* major depressive disorder (severe but short term depression)
* persistent depressive disorder (long term or recurring depression)
* disruptive mood disregulation disorder (childhood temper tantrums)
* premenstrual dysphoric disorder (disruption to mood prior to/during menstruation
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behavioural characteristics of depression
* **activity levels** (reduced energy levels - lethargy, withdrawal from work, education and social life. psychomotor agitation - struggling to relax + pace)
* **disruption to sleep and eating bhv** (insomnia + hypersomnia, appetite may increase or decrease leading to weight gain or loss)
* **aggression and self-harm** (irritable, verbally/physically aggressive = knock on effects e.g. quitting a job. physical aggression against self - self harm/suicide attempts
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emotional characteristics of depression
* **lowered mood** (defining emotional element but more pronounced than feeling lethargic/sad → worthless/empty)
* **anger** (frequently experience anger directed as self or others, can lead to aggressive or self-harming behaviour
* **lowered self-esteem** (like themselves less than usual, can be extreme like self-loathing)
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cognitive characteristics of depression
* **poor concentration** (unable to stick to tasks, hard to make decisions, interfere with work)
* **dwelling on the negative** (inclined to pay more attention to negative aspects of a situation and ignore positive and have a bias towards recalling unhappy events)
* **absolutist thinking** (black and white thinking - unfortunate situation is seen as an absolute disaster)
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statistical infrequency
implies a disorder is abnormal if its frequency is more than two standard deviations away from the mean incidence rates represented on a normally distributed bell curve (when an individual has a less common characteristic)
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statistical infrequency and IQ
* average IQ = 100
* in normal distribution 68% have a score from 85-115
* only 2% have a score below 70
* those below 70 are abnormal and would receive a diagnosis of intellectual disability disorder
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deviation from social norms
when a person behaves in a way that is different from how we expect people to behave - groups choose to define behaviour as abnormal on the basis that it offends their sense of what is the norm
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how are norms specific to the culture we live in?
norms may be different for each generation and every culture → few behaviours that would be considered universally abnormal on the basis they breach social norms

(homosexuality was considered abnormal in our culture and continues to be viewed as abnormal in some cultures - Brunei = laws that make gay sex punishable by death)
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how is antisocial personality disorder a deviation from social norms?
one symptom is an absence of prosocial internal standards associated with failure to conform to lawful and culturally normative ethical behaviour → psychopaths are abnormal because they don’t conform to moral standards
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failure to function adequately
occurs when someone can no longer cope with the demands of everyday life - e.g. unable to maintain nutrition and hygiene or can’t hold down a job
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when is someone failing to function adequately?
Rosenhan and Seligman:

* a person no longer conforms to standard interpersonal rules, e.g. maintaining eye contact
* experiences severe distress
* behaviour becomes irrational and dangerous to themselves or others
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FFA in intellectual disability disorder
a diagnosis would not be made on having statistical infrequency alone, they must also be failing to function adequately before a diagnosis would be given
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deviation from ideal mental health
occurs when someone doesn’t meet a set of criteria of good mental health and what would compromise ideal mental health (Jahoda)
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what does ideal mental health look like?
* no symptoms of distress
* rational and can perceive ourselves accurately
* we self-actualise
* can cope with stress
* have a realistic view of the world
* good self esteem and lack of guilt
* independent of other people
* can work, love and enjoy our leisure
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strength of failure to function adequately: represents a threshold for help
* most have symptoms of mental disorder to some degree at some time
* Mind: 25% of people in the UK will experience a mental health problem in any given year
* many press on in the face of fairly severe symptoms
* at the point we cease to function adequately people seek professional help/noticed and referred to help
* treatment can be targeted to those who need it the most
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limitation of failure to function adequately: discrimination and social control
* easy to label non-standard lifestyle choices as abnormal
* its hard to say when someone is really failing to function and when they have just chosen to deviate from social norms
* not having a job or permanent address might seem like failing to function but people with alternative lifestyles choose to live ‘off-grid’
* those who favour high risk leisure activities or unusual spiritual practices could be classed, unreasonably as irrational or a danger to self
* freedom of choice may be restricted