clinical psych last min

What was the “Great Confinement” and why was it important?

Foucault (1961) argued that during the Enlightenment, “madness” became institutionalised across Europe. The mentally ill were confined in asylums and became subjects of medical study, marking the beginning of psychiatry as a formal discipline.

What was the significance of the County Asylums Act (1808) and Lunacy Act (1845)?

The County Asylums Act was the first UK mental health legislation requiring care for “pauper lunatics.” The Lunacy Act later redefined mentally ill people as “patients” rather than “inmates,” reflecting the belief that mental illness was treatable.

What distinction emerged between neuroses and psychoses in the 19th century?

• Neuroses involved anxiety, fear, mood disturbance, and preserved reality testing.

• Psychoses involved impaired reality testing, hallucinations, and delusions.

Why is Emil Kraepelin considered foundational to modern psychiatry?

Kraepelin developed a syndrome-based classification system for mental illness, emphasising symptom patterns rather than isolated symptoms. His taxonomy heavily influenced DSM and ICD diagnostic systems.

What is the Kraepelinian dichotomy?

Kraepelin separated psychoses into:

• Dementia praecox → later schizophrenia

• Manic depressive illness → later bipolar disorder

Why was DSM-III (1980) historically significant?

DSM-III introduced operationalised diagnostic criteria and adopted a Kraepelinian medical model, improving diagnostic reliability through standardised symptom checklists.

What was the psychopharmacological revolution?

Between 1945–1965, drugs such as lithium, chlorpromazine, antidepressants, and benzodiazepines transformed psychiatry by making symptoms more manageable and increasing psychiatry’s medical legitimacy.

What criticisms emerged regarding psychotropic medication?

Many drugs caused significant side effects, dependency, withdrawal problems, and overprescribing, raising concerns about purely biological approaches to mental illness.

What is the scientist-practitioner (Boulder) model?

Developed at the 1949 Boulder Conference, it proposed that clinical psychologists should integrate research, diagnosis, and therapy within evidence-based practice.

How did UK clinical psychology differ from the US approach?

UK clinical psychology, influenced by Hans Eysenck, initially prioritised assessment and research over psychodynamic therapy, which Eysenck criticised as unscientific.

Why was Hans Eysenck influential in UK clinical psychology?

Eysenck promoted empirical, evidence-based psychology and rejected Freudian psychoanalysis, helping shape CBT-oriented UK clinical psychology.

What was Albert Ellis’s main contribution to psychotherapy?

Ellis developed Rational Emotive Behaviour Therapy (REBT), proposing through the ABC model that irrational beliefs, rather than events themselves, cause emotional distress.

What was Aaron Beck’s contribution to clinical psychology?

Beck developed Cognitive Therapy, arguing that maladaptive schemas and cognitive distortions maintain emotional disorders such as depression.

Why did CBT become dominant in modern clinical psychology?

CBT combined cognitive and behavioural approaches into a structured, brief, evidence-based therapy strongly supported by research and NICE guidelines.

What is Evidence-Based Practice (EBP) in clinical psychology?

According to APA (2006), EBP integrates:

1. Best research evidence

2. Clinical expertise

3. Patient values/preferences
   It underpins modern NHS psychological treatment and NICE guidance.

What is Major Depressive Disorder (MDD)?

A mood disorder characterised by persistent low mood and/or loss of interest/pleasure lasting at least 2 weeks, causing clinically significant distress or impairment (DSM-5).

What are the core DSM-5 symptoms of MDD?

Five or more symptoms over 2 weeks including:

• depressed mood

• anhedonia

• sleep/appetite change

• fatigue

• guilt/worthlessness

• poor concentration

• psychomotor changes

• suicidal ideation

Why is diagnosis of depression criticised?

Criticisms include:

• symptom overlap with normal distress

• cultural bias in DSM criteria

• heterogeneity of presentations

• high comorbidity with anxiety

• reliance on subjective self-report

What did Haroz et al. (2017) show about depression cross-culturally?

Depression symptoms vary across cultures and may include loneliness, anger, headaches, aches/pains, and “thinking too much,” which are not emphasised in DSM-5.

What is the prevalence and impact of depression?

WHO (2025):

• ~5.7% global adult prevalence

• more common in females

• leading cause of disability worldwide

• associated with suicide, occupational impairment, and cognitive dysfunction

What is the monoamine hypothesis of depression and its critique?

Depression results from reduced levels of serotonin, norepinephrine, and dopamine in the CNS.

The STAR*D trial showed only around one-third achieve remission after first antidepressant treatment, suggesting depression is more biologically complex (Pigott, 2015; Cui et al., 2024).

What is Lewinsohn’s behavioural model of depression?

Depression develops through reduced response-contingent positive reinforcement, leading to withdrawal and decreased activity.

What is Behavioural Activation (BA)?

A therapy based on behavioural models that increases rewarding activities to improve mood and reduce avoidance (Martell et al., 2001).

What is Ellis’ REBT model?

Emotional distress is caused by irrational beliefs rather than events themselves.
ABC model:

• A = Activating event

• B = Beliefs

• C = Consequences

What is Beck’s cognitive theory of depression?

Depression is maintained by negative schemas and the cognitive triad:

• negative view of self

• world

• future

What are cognitive distortions in Beck’s model?

Biased thinking patterns such as:

• arbitrary inference

• selective abstraction

• magnification/minimisation

• overgeneralisation

What is anxiety and how does it differ from fear?

• Anxiety = anticipation of future threat

• Fear = response to immediate threat

• Both involve sympathetic nervous system arousal.

What is the Intolerance of Uncertainty (IU) model of GAD?

People with GAD experience uncertainty as threatening, leading to chronic worry, cognitive avoidance, and negative problem orientation (Dugas & Koerner, 2005).

What are the main evidence-based treatments for depression and anxiety?

• CBT

• Behavioural Activation

• medication (SSRIs/benzodiazepines etc.)

• applied relaxation
  CBT is strongly supported by NICE guidelines and meta-analytic evidence.

What is psychosis?

• Umbrella term for experiences involving loss of contact with shared reality.

• Symptoms:

  • Hallucinations

  • Delusions

  • Disorganised thinking

  • Disturbed reality testing

What is schizophrenia?

• A psychotic disorder characterised by:

  • Positive symptoms

  • Negative symptoms

  • Cognitive difficulties

• Usually chronic and functionally impairing.

Schizophrenia: Positive vs negative symptoms

Positive symptoms (added experiences)

• Hallucinations

• Delusions

• Disorganised speech

Negative symptoms (losses/reductions)

• Avolition

• Flat affect

• Apathy

• Social withdrawal

Epidemiology of schizophrenia (McGrath et al., 2008)

• Lifetime prevalence ≈ 1%

• Equal male/female risk

• Mortality risk 2–3x higher

• High suicide risk:

  • 5% die by suicide

  • 20–50% attempt suicide

Schizophrenia Biological causes: genetics

Risk increases with genetic relatedness:

• General population = 1%

• One parent diagnosed = 10%

• Non-identical twin = 12%

• Identical twin = 50%

BUT:

• No single “schizophrenia gene”

• Polygenic vulnerability.

Dopamine hypothesis

Schizophrenia linked to excess dopamine activity.
Evidence:

• Antipsychotics block dopamine

• Amphetamines/cannabis can induce psychosis

• Dopamine drugs in Parkinson’s can cause psychotic symptoms

Critique:

• Oversimplified

• Dopamine abnormalities not specific to schizophrenia

• Other neurotransmitters implicated (GABA, glutamate, serotonin)

Psychosocial causes of psychosis

Major social risk factors:

• Childhood trauma

• Poverty/deprivation

• Migration

• Racism/discrimination

• Chronic stress

Key idea:
Psychosis is strongly socially patterned.

Trauma and psychosis evidence

• Varese et al. (2012):
  Trauma significantly increases psychosis risk.

• Barrigon et al. (2015):
  Childhood adversity strongly linked to psychotic symptoms.

Trauma-informed approaches now central.

Continuum model of psychosis

Psychotic experiences exist on a spectrum.
Examples:

• Paranoia common in general population

• Voice hearing reported by many non-clinical individuals

Key studies:

• Bebbington et al. (2013)

• Beavan et al. (2011)

One-factor theory of delusions (Maher, 1974)

Delusions are:

• Normal explanations

• For unusual/anomalous experiences

Suggests reasoning may remain broadly intact.

Stress-vulnerability model (Zubin & Spring, 1977)

Psychosis develops through interaction between:

• Biological vulnerability
  AND

• Environmental stress

Protective environments can reduce risk.

Classic biopsychosocial model.

What is psychological formulation?

Collaborative explanation of:

• Why problems developed

• What maintains them

• What may help recovery

Focuses on:

• Trauma

• Relationships

• Meaning

• Social context

CBT for psychosis (CBTp)

CBTp focuses on:

• Meaning of voices/delusions

• Coping strategies

• Distress reduction

• Relapse prevention

Evidence:

• Small–medium benefits

• Stronger in first episode psychosis

Critique:

• Effects modest

• Often symptom-focused

Diagnosis vs formulation debate

Diagnosis

• Standardised

• Useful for services/research

• Medical model

Formulation

• Individualised

• Collaborative

• Contextual

• Trauma-informed

Key exam debate:
“Understanding disorders” vs “understanding people.”

What is trauma?

Exposure and response to distressing events.
Shift in care:

• “What happened to you?” not “What’s wrong with you?”

What is PTSD?

Trauma disorder involving:

• intrusions

• avoidance

• negative mood/cognition

• hyperarousal

Must cause distress/impairment.

What is Complex PTSD?

PTSD +:

• emotional dysregulation

• relationship difficulties

• negative self-concept

Usually linked to chronic/interpersonal trauma.

Key study: Cloitre et al. (2014)

What are ACEs?

Adverse Childhood Experiences:

• abuse

• neglect

• violence

• parental dysfunction

Linked to poorer mental and physical health.

How does trauma affect the brain?

• Overactive amygdala

• Impaired hippocampus

• Reduced prefrontal regulation

Key study: Liberzon & Abelson (2016)

Behavioural explanation of PTSD

Trauma becomes associated with neutral cues through conditioning.

Avoidance reduces anxiety short term but maintains PTSD long term.

Emotional Processing Theory

Edna Foa:

• PTSD = pathological fear network

• Avoidance prevents emotional processing

• Exposure activates and restructures fear memories

Cognitive Theory of PTSD

Ehlers & Clark:
PTSD maintained by:

• negative appraisals

• fragmented trauma memories

• sense of current threat

Dual Representation Theory

Chris Brewin:

• C-Reps = contextual memories

• S-Reps = sensory flashbacks

PTSD involves strong S-Reps and weak C-Reps.

What is Prolonged Exposure Therapy?

Repeated exposure to:

• trauma memories

• avoided situations

Mechanisms:

• fear extinction

• reduced avoidance

Key study: Feeny et al. (2017)

What is EMDR?

Eye movement desensitization and reprocessing:

Trauma memories recalled during bilateral eye movements.

Possible mechanism:

• working memory taxation

Key study: Ramon Landin-Romero et al. (2018)

Criticisms of PTSD diagnosis

• reductionist

• symptom-focused

• ignores personal meaning/context

• people with same diagnosis differ greatly

What is trauma-informed care?

Approach emphasising:

• safety

• collaboration

• empowerment

• understanding trauma context

What is vicarious trauma?

Trauma impact on professionals working with survivors.

Effects:

• burnout

• compassion fatigue

• PTSD symptoms

DSM-5 criteria for insomnia disorder?

Difficulty initiating/maintaining sleep despite opportunity, causing distress/impairment, 3x weekly for 3+ months.

Main insomnia consequences?

Fatigue, emotional dysregulation, cognitive impairment, accident risk, poorer mental health.

Three processes controlling sleep?

Homeostatic (sleep pressure), circadian rhythm, psychological processes.

What is process S and process C?

S = Homeostatic sleep pressure driven by adenosine accumulation.

C = Circadian rhythm controlled by the biological clock and light exposure.

What does caffeine do in sleep regulation?

Blocks adenosine receptors, reducing sleep pressure.

Main limitation of actigraphy?

Still wakefulness may be recorded as sleep.

What does polysomnography measure?

• Brain electrical activity and sleep stages.

What are the stages of sleep?

N1 (drowsy), N2 (light), N3 (deep), REM.

Spielman’s 3P model?

3 factors maintaining insomnia.

1. Predisposing factors

People with insomnia can be characterised by a behavioural phenotype showing

§  Attentional bias

§  Higher trait anxiety

§  A propensity to ruminate/catastrophize

2. Precipitating factors

Something happening in ones life to bring this one

§  Stress increase

§  Bereavement

§  Having a child

§  Moving from home

§  Transitional period

§  Moving sleep environment

3. Perpetuating factors

Behavioural factors that continue sleep problems

§  Extending time in bed not sleeping

·      Associates the bed with being awake

Espie et al. A-I-E pathway?

Attention → intention → effort creates hyperarousal and insomnia. The model posits that the harder you try to sleep, the more elusive it becomes.

Core components of CBT-I?

Stimulus control, sleep restriction, cognitive therapy, relaxation, sleep hygiene.

NICE guidance on insomnia treatment?

CBT-I first line; hypnotics only after non-pharmacological approaches considered.

Define dissociation

Dissociation = disconnection between thoughts, memories, emotions, identity, body, or surroundings; often trauma-related.

Adaptive survival response reducing awareness of overwhelming emotional/physical pain.

What are psychoform vs somatoform dissociation?

Psychoform = psychological symptoms; somatoform = physical symptoms (e.g. paralysis, seizures, numbness).

What is dissociative amnesia?

• Memory gaps inconsistent with ordinary forgetting, often involving trauma or periods of life.

Difference between depersonalisation and derealisation

Depersonalisation = detached from self/body.
Derealisation = surroundings/world feel unreal or distorted.

What is DID?

Dissociative Identity Disorder involves two or more identity states plus memory gaps and distress.

How common are dissociative disorders?

• Estimated 3–18% prevalence in general population; DID around 1.5%.

Why is dissociation considered transdiagnostic?

Occurs across many disorders including PTSD, CPTSD, psychosis, BPD, anxiety, and depression.

Why is dissociation difficult to identify?

Called a “disorder of hiddenness” because symptoms are often minimised, misunderstood, or misdiagnosed.

What is the SCID-D?

• Structured Clinical Interview for Dissociative Disorders; gold-standard assessment tool measuring 5 dissociative domains.

What is the trauma model of dissociation?

• Early trauma and attachment disruption predict later dissociative difficulties.

What is Liotti’s attachment model?

Frightened/frightening caregiving creates “fear without solution,” leading to dissociative splitting.

What is structural dissociation theory?

• Personality divides into trauma-avoidant ANPs (“apparently normal parts”) and trauma-focused EPs (“emotional parts”).

What is the phase-oriented treatment model?

A sequential, three-stage therapeutic approach primarily used for trauma and complex dissociative disorders.

Phase 1 = safety/stabilisation
Phase 2 = trauma processing
Phase 3 = integration and rehabilitation.

Define autism spectrum disorder (ASD)

Autism Spectrum Disorder is a lifelong, diverse condition affecting communication, social interaction, behaviour, and sensory processing.

How common is autism?

Around 1 in 100 people are autistic in the UK. National Autistic Society

Why have autism diagnoses increased?

Greater awareness, broader diagnostic criteria, and improved recognition in adults and females.

What are the core diagnostic features of autism?

Persistent social communication difficulties plus repetitive/restrictive behaviours and sensory differences.

What are examples of repetitive/restrictive behaviours in ASD?

Insistence on sameness, highly focused interests, routines, stereotyped movements.

What sensory differences may autistic people experience?

Hyper- or hypo-sensitivity to sound, light, touch, taste, or texture.

What are meltdowns and shutdowns in ASD?

Meltdowns = overwhelming emotional/sensory reactions; shutdowns = withdrawal and reduced functioning.

What is Theory of Mind theory?

• Simon Baron-Cohen proposed autistic people may struggle to infer others’ thoughts or feelings.

What is the double empathy problem?

Misunderstanding between autistic and non-autistic people is mutual, not one-sided.

What is the medical vs social model of disability?

Medical: Views disability as a problem within the individual requiring treatment or cure.
Social: Disability results largely from societal barriers, exclusion, and inaccessible environments.

Why are autistic people at greater mental health risk?

Higher rates of anxiety, depression, bullying, discrimination, and social exclusion.

What is masking in autism?

Concealing autistic traits to fit social expectations, often causing stress and burnout.

What interventions may support autistic people?

Speech therapy, occupational therapy, CBT, mental health support, ABA, music/play therapy.

Key conclusion from the social model of autism

Autistic people may have impairments, but many difficulties arise from societal attitudes and lack of accommodation.

What is IAPT (NHS Talking Therapies)?

IAPT (now NHS Talking Therapies) provides evidence-based psychological treatments for adults with anxiety and depression, mainly using CBT and related therapies, available via self-referral or GP referral.

For: Adults (18+) with mild to moderate depression or anxiety disorders. It is not designed for severe, complex, or crisis presentations.

What is the stepped care model?

A system where people receive the least intensive effective intervention first, with escalation to more intensive treatments if needed.

• Step 1: GP / initial assessment

• Step 2: Low-intensity support (guided self-help, workshops)

• Step 3: High-intensity therapy (CBT, IPT)

• Step 4: Specialist care (complex, high-risk cases, inpatient/ECT)

What is the purpose of NICE guidelines?

NICE provides evidence-based recommendations to ensure psychological treatments are standardised, effective, and cost-efficient in NHS services.

What therapies are used in IAPT?

• CBT (main approach)

• Guided self-help

• Counselling for depression

• IPT

• Trauma-focused CBT (for PTSD)